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Analysis of Ways of Knowing in NursingSamantha SotoUniversity of Central FloridaCollege of NursingAnalysis of Ways of Knowing in NursingHistorically in the discipline of nursing, knowledge development and nursing science have been a controversial battle to tackle. Most theorists agree that nursing is comprised of both artistic components along with scientific elements. It is a discipline that is profoundly unique from others that must involve knowledge base, maintenance, and development from artistic and scientific theories, research, and ways of knowing. Nursing theory began its most primitive theoretical documentation in 1859 by Florence Nightingale, where she discussed the purview of nursing, and stated that, “to nurse meant having charge of the personal health of someone.” She was the first to advocate the teaching of symptoms and what they indicated; advocate for nurses to record observations; develop knowledge about factors that promoted healing; and emphasize that knowledge developed and used by nurses should be distinct from medical knowledge. (McEwen & Wills, 2011)It would not be until 119 years later, in 1978, that another notable nurse would finally link the issue of how nurses acquire knowledge, skill, and conduct research into a work known as “Fundamental Patterns of Knowing” by Barbara Carper RN EdD. Schultz & Meleis (1988) describe epistemology as the study of the theory of knowledge that includes: What do we know? What is the extent of our knowledge? How do we decide whether we know? and What are the criteria of knowledge? Carper’s (1978) elements include the elements of empirics, esthetics, personal knowledge, and ethics. She described empirics as the science of nursing, esthetics as the art of nursing, personal knowledge, and ethics as moral knowledge in nursing. Recently, another nurse known as Jill White, CM, Med, a college professor prepared a manuscript titled, “Patterns of knowing: Review, critique, and update,” where she discusses Carper’s “Fundamental Patterns of Knowing” and includes sociopolitical knowing. Recently I was given the opportunity to care for a gentleman of 39 years of age who was admitted with a diagnosis of chest pain. Historically he had a cardiac catheterization 4 weeks prior for a myocardial infarction and had 2 stents placed in his coronary arteries. He is obese, smokes, does not follow any special diets and often refuses to take medications. He had testicular cancer two years ago and is currently in remission. He tells me his father died of a myocardial infarction in his early 40’s and that his father’s family has several relatives that suffer from cardiovascular disease. He states he is scared and that he does not want to leave his wife alone in this world because she nor he could live without each other. He briefly addresses the loss of child who passed unexpectedly at the age of 6 several years ago. Below in table 1, table 2, table 3, table 4, I have presented his laboratory studies, vital signs, morning assessment, education plan, and care plan. Table 1 Laboratory Studies0800Laboratory StudiesFirst Day’s StudiesSecond Day’s StudiesThird Day’s StudiesCBCWBC13119H/H1514.514.7PLT300320315BMPGLU110105101Ca+8.599Na+134136136K+444.3CO2323030Cl107106105BUN302518Creat1.51.31.0CardiacCPK260230250Trop<0.012<0.012<0.012Table 2 Vital Signs 0800VitalsTemp98.7HR85R18BP126/74 O297%RA Table 3 Assessment0800AssessmentPsycDiscusses death of his son at the age of 6 by a tragic and unexpected eventRespRA, all lobes are clear, no coughCardioRegular, NSR, no edema, peripheral pulses are 2+GI+BS, abdomen soft non-tender, last BM yesterday, c/o having heartburn dailyGUVoids via urinal, clear, straw colorM/SAmbulates without assist and has steady gaitNeuroAOx4, grips are equal, limb strength is equal, PERRLAEENTVisual deficit, wears glassesSkinR groin puncture from recent heart cath, healing wellPainc/o epigastric and possible chest pain 6/10IV/Fluids#20 R forearm dated yesterday, running NS@75Table 4Education PlanCardiac catheterization teachingCardiac diet teachingSafety awarenessCare PlanRisk for infectionRisk for infarctionRisk for painApplicationThe problem that I will highlight is the patient having chest and epigastric pain after recently having a myocardial infarction. Applying Carper’s “Ways of Knowing” topic of empirics encourages me to provide direct and indirect observation and measurement. The patient’s assessment and vital signs were taken and documented as listed above. His laboratory values were reviewed as well and after confirming them I placed a phone call to the cardiologist consulted to his case. I received orders for an EKG, nitro sublingual, morphine 2 mg IV, O2 2L via nasal cannula, aspirin 325mg, and he stated he would be down shortly to see the patient. After following the orders I received the patient did not have any relief of his pain. The physician determined that the patient would need to be taken to the cardiac catheterization laboratory emergently. My experience in nursing for eight years along, with my certification as a cardiac/vascular nurse permitted me to recognize that the patient’s symptoms of pain and epigastric combination could be serious. Within Carper’s concept of esthetics, she discusses the art of nursing as being subjective, expressive, and experiential. I applied this concept to the patient’s situation by praying with the patient and his wife. They were worried, scared, and exhausted after having another admission to the hospital regarding his health. As I was present and explaining to them some of the things they could expect, they began discussing death and the death of their child. They cried together and provoked the profound emotion within me as well at this moment. I could detect that this family was in crisis. The gentleman turned to me and asked me if I was a Christian and asked me if I would pray with them. I responded, “Certainly,” and we said a brief prayer. By praying with the patient it allowed me to empathize with this patient and his wife. My situation may never be the loss of a child, but the prayer allowed me to connect with them spiritually and address the humanity within nursing. Personal knowledge is Carper’s third concept presented in her document. She describes it as the knowing, encountering, and actualization of the concrete, individual self. Carper (1978) goes on to state that the relation is one of reciprocity, a state of being that cannot be described or even experienced-it can only be actualized. She also states that because personal knowledge is difficult to express linguistically, it is largely expressed in personality. This is the stem of nursing that requires the nurse to desire connectivity with their patients to facilitate the nurse to patient relationship. It does have some overlapping features similar to esthetics, however differs in the nurse and patient desiring to create a therapeutic relationship. In the case of my 39 year old patient I facilitated our connection by sitting in a chair at his bedside to discuss pre cardiac catheterization procedures with him and his wife. We were at eye level, I placed my hand on his shoulder and I assured him that he was in good hands. We discussed the fact that he was young and still relatively healthy, despite his bad habits and that we needed to cross this road so we could get to the next part of his journey. I called it, “the better you journey.” The patient’s behavior, facial gestures, and questions, demonstrated fear of dying and leaving his wife alone. My personal knowledge as a nurse and human being allowed me to rationalize his fear and help him cope with his feelings. Carper (1978) presented her fourth “Way of Knowing” as ethics. She describes ethics as a moral code that is based on obligation to service and respect for human life. Carper (1978) states that ethics requires rational and deliberate examination and evaluation of what is good, valuable, and desirable goals, motives, or characteristics. The ethical dilemma that presented itself in this case was the return to the cardiac catheterization laboratory and the risks of having this procedure so recent to his last cardiac catheterization. My personal knowledge and experience tells me that patients are occasionally at risk for kidney distress from the iodine dye that is utilized in procedure, along with the risk of allergic reaction to the dye, bleeding, bruising, and rarely occurring, tearing or puncture of an artery, emergent cardiothoracic surgery, and even death. All of his risks were evaluated and his physician felt that it was in his best interest to return to the cardiac catheterization laboratory due to the possibility of stent reocclusion. The patient and his wife spoke and decided that he should revisit the catheterization laboratory. Carper (1978) states that the discipline of nursing is held to be a valuable and essential social service responsible for conserving life, alleviating suffering and promoting health. In his case, it is certain that his health was being conserved so we the topic of reocclusion of stents and cardiac catheterization procedure and what to expect before and after his procedure. I provided the patient with the appropriate information allowing him to make the best decision for himself, an informed one. Lastly, another nurse and professor, Jill White RN, CM, MEd, presented her “Patterns of knowing: Review, critique, and update,” to the world in 1995 adding the element of sociopolitical knowing. She states that the pattern of sociopolitical knowing addresses the “where in,” and that it includes the sociopolitical context of the persons, the sociopolitical context of nursing as a practice profession; including both society’s understanding of nursing and nursing’s understanding of society and its politics. White states that violence, drug dependence, and diabetes are examples of responses to what are inherently political rather than simply personal problems, and nurses’ efforts to deal with them require nurses to articulate what they see resulting from societies’ structures. With that said, in relation to the patient presented, we discussed his familial history of heart disease, along with the risk factors associated for heart disease. Upon this discussion we revealed his smoking habit as a preventable risk factor and I instructed the patient on smoking cessation verbally and also gave the patient some materials to read himself. He stated that he no longer wanted to smoke because he was afraid he would have another heart attack. Sociopolitically, smoking is finally being viewed as a demon to our health. The government is now placing realistic advertisements on television, branding the cigarette packets with actual pictures of disease and death, and providing free materials to those that want to quit smoking. As a nurse I can facilitate smoking cessation by teaching techniques and giving the materials they supply for patients. Nursing continues to evolve and with its recent push for deeper education we will notably create change among our profession and in the world. Carper and White have merely set the foundation for what can and should be cultivated. Describing to us their “Ways of Knowing,” empirics, esthetics, personal knowledge, ethics, and sociopolitical knowing are all methods that we can effortlessly apply to our daily practice regardless of what kind of environment we perform in. In order to obtain the distinguished regard nursing deserves we must continue to apply works such as: “Fundamental Patterns of Knowing,” and “Patterns of knowing: Review, critique, and update,” to our education, practice, and research. ReferencesCarper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1):13-23McEwen, M. & Willis, E. (2002). Theoretical basis for nursing (3rd Ed.). Philadelphia: Lippincott, Williams & Wilkins. [ISBN: 978-1-60547-323-9]Schultz, P. & Meleis, A. (1988). Nursing epistemology: Traditions, insights, questions. Image: Journal of Nursing Scholarship, 20(4), 217-221.White, J. (1995). Patterns of knowing: Review, critique, and update. Advances in Nursing Science, 17, 73-86. ................
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