Patricia E.

Zander, PhD, RN ^ " ^

Abstract: Using^ Rodger's (2000) model ofconcept analysis the historical evolution ofways ofknowing
in nursing will be discussed. The ways ofknowing in nursing will be explored through their antecedents
of learning styles and knowledge, their attributes, and their consequences. The primary focus of the
article is the four ways or patterns of knowing in nursing identified by Carper (1978) which have
become known as nursing's epistemology. facobs-Kramer and Chinn (1997) later described these ele-
ments of the epistemology in depth with Silva, Sorrell, and Sorrell (1995) using them to explicate the
ontology of nursing.

Key words: Nursing, Historical Evolution of Concept, Ways ofKnowing

Ways of Knowing in Nursing:

The Historical Evolution of a Concept

way in which each person begins to gather, concentrate on,

I n 1978, Carper wrote that nursing sought to develop a

holistic, individualistic, and therapeutic model of practice
that took the profession away from the autocratic, reduction-
ist, and behaviorist characteristics of the medical model. This
futuristic evolution of nursing called for a shift away from the
process, internalize, and remember new and difficult academic
content. Several types of learning styles have been proposed. The
most widely recognized is the Learning Styles Moctel of Dunn and
Dunn (1993), whose model addressed 21 unique learning
ontological and epistemological assumptions associated with "old elements that were classified into five broad categories. The model
school' nursing and nursing education toward a more flexible was based on the cognitive style and brain laterafization theories
paradigm. In order to be able to make this dramatic shift. Carper of learning (Morse, Oberer, Dobbins, & Mitchell, 1998) and
proposed that four ways or patterns of knowing be utilized to took into account the visual, auditory, tactual, and kinesthetic
structure nursing education and evaluate nursing practice. These strengths needed for learning (Dunn & Dunn, 1993).
patterns or ways of knowing were empirics, ethics, esthetics, and Learning style theory conceives of the brain as a unit that
personal. Since the publication of Carper's seminal work, many processes information in one of two ways, globally or analytically.
authors have focused on the four patterns collectively and Global or right brain learners are holistic learners who need to
individually in order to further define and describe them; there understand the overall concept before they can focus on the
have been others (e. g. Benner, 1982, 1983; Munhall, 1993; Rew, details (Morse et al., 1998; Van Wynen, 1997, 1998; Zenhausen,'
1986; White, 1995; Young, 1987) who have proposed additional 1980). They want to know what learning is required and why
ways of knowing. These multiple viewpoints will be presented in (Morse et al.). Analytic or left brain learners (Morse et al.; Van
an analysis of what has come to be known as the epistemological Wynen; Zenhausen) use a sequential, step-by-step, building block
and ontological foundation of nursing. style of learning; they require the details before they can under-
stand the information being presented.
, Using the evolutionary model of concept analysis (Rodgers,
2000), ways of knowing in nursing will be explored through their Learning styles are concerned with the processes of learning
antecedents, attributes, and consequences; exemplars will be (Silver et al., 1997; Snyder, 2000). Gardner (1993, 2001)
provided to illustrate the various ways of knowing in nursing conceived a theory of multiple intelligences that centers on the
practice. The evolutionary model was chosen because it perceives product and the contents of learning. Gardner described human
concepts to be dynamic entities whose attributes are not stable intellectual competence (intelligence) as "the ability to solve
but are in continuous flux and in need of "purposeful redefinition problems, or to create products, that are valued within one or
to maintain a useful, applicable, and effective concept" (Rodgers, more cultural settings" (Gardner, 1993, p. x). Three intelligences
p. 81). Nursing is a dynamic profession and therefore needs are related to the senses in name. The intelligences are not
continual exploration of the various concepts linked to its comparable to sensory systems, but they can be realized through
educational and evaluative processes. several sensory systems (Gardner, 1993).
The learning styles and multiple intelligences theories lead
Ways of Knowing in Nursing: An Evolutionary Analysis the way to what is currently termed the "brain-based" or "whole
Antecedents: Learning Styles and Knowledge brain" approach to learning that is focused on how the brain
Knowing connotes that one has a solid base on which to processes the information it receives. Gaine, Caine, and Growell
structure an action or way of being. That base is knowledge, but in (1994) and Gaine and Caine (1995) state that the brain is a
order to gain knowledge one has to employ a process known as parallel non-linear processor that performs many functions such
learning. Each individual has special means by which he or she as the simultaneous processing of parts and wholes. Therefore the
learns; these are known as learning styles. Because both concepts left and right sides of the brain are interactive in the learning
are the foundation of all knowing, they need to be discussed prior process.
to looking at the attributes of the ways of knowing in nursing. Be it by learning style, multiple intelligences, whole brain, or
Learning styles. Learning styles have been defined by Dunn, a combination of all, nurses acquire their knowledge base from
Denig, and Lovelace (2001), Dunn and Dunn (1993), Dunn and many sources. Nurses use this knowledge in their ways of
Griggs (1998), Gregorc, (1979), Silver, Strong, and Perini (1997), knowing as they practice their profession in many contexts.
and Van Zwanenberg, Wilkinson, and Anderson (2000) as the

The fournal of Theory Construction & Testing -7- Volume 11, Number 1
 Knowledge. Knowledge as an antecedent to the concept
"ways of knowing in nursing"; it is the general knowledge an
individual possesses prior to entering a discipline such as nursing.
Knowledge has been defined as "understanding of or information
about a subject which has been obtained by experience or study,
and which is in either a person's mind or possessed by people
generally" (Cambridge Dictionaries, 2003); as "the fact or
condition of knowing something with familiarity gained through
experience or association, acquaintance with or understanding of
a science, art, or technique" (Merriam-Webster, 2003); or
"awareness, familiarity", or a "person's range of information,
understanding (of a subject)", "information", or a sum of what is
known" (AskOxford, 2003). Chinn and Kramer (1999) defmed
knowledge as "knowing that is in a form that can be shared and
communicated with otriers" (p.l), and describe knowledge as the
accurate representation of the perceived world of a discipline's
members. The development or knowledge through knowing is
considered the epistemologic concern of a discipline (Chinn &
Kramer).
Epistemology, theory of knowledge, derives from two Creek
words: episteme, meaning "knowledge' and logos, meaning, "study
of" or "theory of"; in English epistemology and theory of
knowledge are used interchangeably (Earle, 1992, p. 21). Yorks
and Sharoff (2001) described epistemology as "the relationship
between the person as a seeker of knowledge and the knowledge
itself" (p. 22).
Two types of knowledge are inherent in nurses' ways of
knowing, explicit and tacit. Polanyi (1962) described explicit
knowledge as the formal information gained from written words,
maps, or symbols and tacit knowledge as the knowledge gained
from experience, interaction, and the acquisition and combina-
tion of skills, "knowing that" (Eade, 1992). As one gains experi-
ence, tacit knowledge incteases and there is less reliance on fact
and rules (Halter, 2001) and more discernment of patterns and
forms in the sense of the whole picture rather than of puzzle
pieces that need to be organized. French (1992) identified tacit
knowledge as knowledge that is known by the experts in a
discipline but that is not found in the discipline's literature.
Through repeated experiences and reflections on those experi-
ences the knower comes to rely less on facts and rules or the
particulars in a situation and more on the whole of the situation.
Traditionally, it was alleged that knowledge came about
through sensory collection of information and processing of that
information by the learning centers of the brain. Currently, it is
recognized that there is much more involved in knowledge
acquisition and knowing.
Attributes: Ways of Knowing
Knowing has been defined as being "highly educated, having
extensive information or understanding", being "alert and fully
informed" (OneLook, 2003), "having or reflecting knowledge,
information, or intelligence", and "indicating possession of
exclusive inside knowledge or information" (Merriam-Webster,
2003). Polanyi (1964) defmed knowing as "an active comprehen-
sion of things known, an action that requires skill" (p. xiii, p. xiv).
Chinn and Kramer (1999) described knowing as "an ontologic,
dynamic, changing process" that is associated with how the self
and world are perceived and understood (p. 1). Slife and Williams
(1995) bring knowing to the present consideration with their
statement, "Knowing is vitally involved in every discipline,
though not always explicitly" (p. 65).
Carper's (1975) original definitions and descriptions of the
four patterns (ways) of knowing in nursing, considered by many
to be the epistemology of nursing, will frame a discussion of the
attributes of the concept, while other authors' work will be
utilized to enhance Carper's original ideas. Other ways of
knowing have been proposed and these will be discussed in an
attempt to provide further understanding of this complex
concept.
The Journal ojTheory Construction & Testing
Empirics. Empirics, the science of nutsing, is concerned with
the objective, abstract, and general knowledge that is quantifiable
and verified through repeated testing over time (Carper, 1978,
1992). Empirics was conceptualized by Carper, with substantia-
tion by Sarvimaki (1994), as the objective, absttact, general
knowledge that is methodically arranged into the theoties,
models, and principles that govern the profession. Empirical
knowledge fits Earle's (1992) criteria for knowledge in that it is
believed, true, and justifiable. Liaschenko and Fisher (1999)
termed empirical knowledge "case knowledge" and framed it
within the biomedicai model stating that case knowledge
"legitimizes that aspect of nursing work that is concerned with
monitoring disease processes and therapeutic responses" (p. 34).
By its use of experience when gathering data in research. Booth,
Kenrick, and Woods (1997) believe nursing is devoted to
empirics.
Ethics. Ethical knowing, the moral component, was de-
scribed by Carper (1978) as being concerned with choosing,
justifying, and judging actions involving moral duty, rights, and
obligations. Practicing within an ethical discipline requires a
philosophical foundation concerning the concepts of good, rights,
duties, and oughts. A comprehension of various ethical frame-
works can be used to help clarify ethical problems. Carper (1992)
further describes ethical knowing as "normative and abstract as
well as singular and particular" (p. 75). Ethical decision-making
occurs in the context of a concrete situation; therefore, it is
patticulat, but the decisions made are based on moral principles
that are abstract and general. These principles are considered
universally valid and applicable to all similar situations. Benner
(1991) stated that routine ethics are dependent on the everyday
expert ethical behaviors and moral rationalities inherent with the
knowledge of active knowers. Ethical knowing is couched in
personal values and in a critical exploration oFwhat is desited and
cherished as one's moral fiber, motives, and goals (Carper, 1992).
Esthetics. Carper (1978, 1992) described esthetics, the att of
nursing, as individual, particular and unique. Esthetic knowing
requires the nurse to interpret the patient's behavior in regard to
relationships and wholes rather than separate discrete parts. It was
conceived as going beyond the explanations provided for by
existing principles and theories to account for the intangible
entities. Boykin, Parker, and Schoenhofer (1994) and LeVasseuer
(1992) viewed Carper's descriptions of aesthetics to mean nursing
arts or the skills of nursing and the use of art in nursing practice
rather than the broader experience and expression of creating and
the resulting appreciation of that creativity in the nursing
encounter. Each of these expressions and appreciations is consid-
eted unique to the experience itself and cannot be foreseen.
Bournaki and Cermain (1993) described esthetics as "the art of
nursing that attends to the unique patticulars in the contextual
wholeness of specific situations of nursing care" (p. 82) and is
hard to verbalize. Esthetic knowing assists the nurse in seeing the
whole picture from an evaluative standpoint and envisioning the
outcome of the creative actions chosen for a specific situation.
Katims (1994) described the art of nursing as the expressive,
creative, and intuitive application of formal knowledge situated in
human experience and human action. Sorrell (1994) believed that
esthetic knowing provides the means to enrich the comprehension
of nursing experiences that is not provided by the other ways of
knowing. These multiple conceptualizations of aesthetic knowing
appear to have two commonalities; aesthetic knowing is often
intangible, and it is entrenched in the experiences associated with
the practice of nursing.
Personal. Carper referred to the fourth way of knowing as
personal knowledge rather than the personal way of knowing;
though it is frequently referred to as personal knowing. Personal
knowledge involves an awareness of self and others in a relation-
ship that is subjective, concrete, and existential and does not
require mediation through language (Carper, 1978, 1992;
Liaschenko & Fisher, 1999). Personal knowledge requires
"engagement rather than detachment, and an active, empathetic
Volume 11, Number 1
participation of the knower" (Carper, 1992, p, 77), Jenks (1993), profession. There would be an understanding of nursing by
Jenny and Logan (1992), Moch (1990) and Paterson and Zderad society and an understanding of society and its politics by the
(1976) indicated that personal knowing could only be achieved nurse. White believed the implications of people as products of a
through complex interpersonal relationships. Personal knowing is culture formed the context for the sociopolitical way of knowing.
knowing how to be authentic with others, knowing one's own way When putting these "other ways of knowing" into perspective
of "being with" another person; it focuses on how nurses come to they may be understood as further elucidations of Carper's (1978)
know how to be authentic in relationships with patients (Fawcett personal knowing.
et al,, 2001), Personal knowing involves planned or spontaneous
respectful interaction focusing on a shift or change in a relation- Consequences: Reexamination, Implications and Critique
ship that fosters a new connectedness or transcendence (Moch; Chinn and Kramer (1999) linked knowing and knowledge,
Sarosi, 1968), Moch likened this to an "a ha" or "satori" experi- but in a somewhat different manner. They defined knowing as
ence (p, 159), "ways of perceiving and understanding the self and the world"
and they describe knowing as "an ontologic, dynamic changing
Other Ways ofKnowing in Nursing process" (Chinn & Kramer, p, 1), Knowledge was conceptualized
There are several other ways of knowing that have relevance as knowing that can be communicated and accurately verified.
to the practice of professional nursing. These are experience, They proposed that ways of knowing lead to nursing knowledge,
intuition (the incommunicable form of knowing or tacit know- rather than knowledge being the basis for knowing in nursing,
ing), unknowing, and sociopolitical knowing. Jacobs-Kramer and Chinn (1997) referred to Carper's patterns of
Experience. Benner (1982, 1983, 2001), Benner and Wrubel knowing as knowledge forms to be implemented in nursing.
(1982), and Burnard (1987) explored the experiential way of Knowing re-examined. Chinn and Kramer (1999) devel-
knowing in nursing practice, Benner and Benner and Wrubel oped a model that expanded Carper's work by looking at how
defined experience as knowing through repeated exposure to knowledge is generated, transmitted, and evaluated. Their model
situations leading to refmement of earlier ideas and thoughts. This has three dimensions: The creative, the expressive, and the
type of knowledge is "knowing how" or knowledge-as-ability assessment. The creative dimension is concerned with the
(Earle, 1992), Burnard described experiential knowing in the generation, extension, and modification of knowledge. Empirical
context of an interpersonal relationship saying it was the subjec- knowledge is created through the familiar quantitative research
tive and the emotional aspect of the relationship leading to methodologies; ethical knowledge involves valuing, clarifying, and
knowledge and that experiential knowing is personal, distinctive, advocating; personal knowledge involves encountering, focusing
and difficult to put into words, Benner (2001) believed "knowing on, and realizing self and others, and aesthetic knowledge is
that" was the focus of Carper's work and not "knowing how" involved with engaging, interpreting, and envisioning Qacobs-
gained from experience. Experiential knowing is said to lead to Kramer & Chinn, 1997, p, 327), The expressive dimension
intuition, the incommunicable or tacit way of knowing. provides the means by which the knowledge pattern is exhibited
Intuition. Young (1987) initially defined intuition as "a and displayed. Empirical knowledge is expressed in facts, theories,
process whereby the nurse knows something about a patient that models, or descriptions used to convey understanding; ethical
cannot be verbalized, that is verbalized with difficulty, or for knowledge is expressed through codes, standards, theories, and
which the source cannot be determined" (p,52). Intuition is descriptions of ethical decision making; personal knowledge is
perceived by many to be the opposite of empirical knowledge in expressed as being an authentic and disclosed self; and aesthetic
that it is subjective and unverifiable. Traditionally intuitive knowledge is expressed through the artful nursing act (Jacobs-
processes were not considered valuable because they cannot be Kramer & Chinn, 1997, p, 329), The third dimension of the
rationally explained (Rew, 1986, 1989; Miller & Rew, 1989), model, assessment, was conceived of as the means by which the
Young offered the viewpoint that while intuition is difficult to four ways of knowing are examined for adequacy of the knowl-
describe there are still objective and predictive thought processes edge pattern by identifying a process context specific to the
present, Agan (1987) defined intuitive knowing as a "non-rational knowledge generation in each pattern, and establishing a pattern-
process based on feeling or sensing" and as an awareness that may credibility index. Empirical knowledge answers representation
come from the subconscious data" (p, 66), Sensing is not the only questions through a process of replication; credibility is estab-
contributor to intuition according to Cosier and Aplin (1982) and lished through validation. The ethical pattern of knowing answers
Gerrity (1987), There may be a "sixth sense" or insight, or innate questions related to moral rightness through a process of dialogue;
skill in unifying various complex bits of data (Cosier & Aplin; credibility is established through justness of an action. Personal
Gerrity; Miller & Rew, 1989; Rew, 1986, 1989), likened to right- knowledge answers questions about knowing and doing through
brained learning by Cosier and Aplin, Benner (1982) character- the process of response and reflection; credibility is established
ized the expert nurse as intuitive based upon vast amounts of through congruity of answers. Esthetics answers the question
experience that leads to "knowing how" that cannot be logically "What does this mean?" through the process of criticism;
explained (Benner, 1983), credibility is established through consensual meaning between the
Unknowing. In 1993, Munhall proposed that another way of nurse and the other(s) in the situation. This model
knowing in nursing was "unknowing", a position of openness in operationalized Carper's work,
contrast to knowing that is a position of closure (p, 125), This Ontological implieations. Retsas (1994) posited that the
position of openness is necessary in order to understand the nursing profession was in a crisis because the ontological dimen-
complex realities of people and their world-view, Munhall states sions of Carper's (1978) ways of knowing had not been given
for a nurse "to be authentically present to a patient is to situate adequate attention, Silva, Sorrell, and Sorrell (1995) credited
knowledge in one's own life and interact with full unknowingness Carper with taking nursing's epistemology from an almost purely
about the other's life" (p, 125); this leads to the openness that scientific perspective to one that was very diverse and complex
allows the nurse to be truly empathetic and understand the encompassing creativity and sensitivity but believed the work had
essence of the situation for the patient, some limitations, Silva et al believed the four ways of knowing
Sociopotitical. White (1995) proposed that there needed to were mutually exclusive, instead of interrelated as Carper concep-
be a fifth way of knowing in nursing, the sociopolitical. In this tualized them. These authors argued that Carper's ways of
proposition. White stated that the other ways of knowing were knowing were exhaustive, rather than subject to revision. Al-
concerned with the "who", "how", and "what" of nursing practice though Carper alluded to evolving concepts for nursing knowl-
and the sociopolitical would deal with the "wherein" (p, 83), This edge development, the idea of a process was negated by her
aspect of knowing would encompass the contexts not only of the conceptual descriptions which read like ends in themselves, not a
nurse-patient relationship, but also of nursing as a practice means to an end. In answer to these stated limitations of Carper's
The Journal ofiTheory Construction & Testing -9 - Volume 11, Number 1
epistemology of nursing, and with regard ro Retsas concern, Silva
et al (1995) proposed on ontology of being, "what it means to be
a nurse and to experience the practice of nursing" (Chinn, 2001,
p. 292), and coined two terms to frame that ontology; "the in-
between" and "the beyond". "The in-between" was conceived of as
"what exists or reveals itself through nonlinear, meditative
thinking that moves in all directions and depths while "the
beyond" was "those aspects of reality, meaning, and being that
persons only come to know with difficulty or they cannot
articulate or ever know" (p. 3). These conceptualizations were
alleged to work in concert with Carper's ways of knowing to
provide the balanced philosophical perspective that nursing was
missing. The epistemological questions associated with the
patterns of knowing become reality-focused questions for the
ontological foundation of nursing. Silva et al. used Carper's ways
of knowing to create nursing's ontology, thereby adding a vital
aspect to understanding the practice of professional nursing.
Major criticisms. There have been criticisms of Carper's
(1978) work primarily focusing on what was believed to be
Carper's failure to develop the aesthetic pattern or way of knowing
(Boykin, Parker, & Schoenhofer,1994; Wainwright, 2000) even
though Carper (1978) had indicated that the descriptors for the
ways of knowing were not complete. Several authors (Bournaki &
Germain, 1993; Chinn & Kramer, 1999; Chinn, Maeve, &
Bostick, 1997; Chinn & Watson, 1994; Eisner, 1985; Smith,
1992; Sorrell, 1994), as well as Boykin et al., took up the chal-
lenge and explored the aesthetic pattern. The other major
criticism by Boykin et al. (1994) was that Carper did not make a
distinction between knowing and knowledge when she called
three of the patterns ways of knowing and then referred to the
fourth pattern as personal "knowledge". The authors believed that
this would lead to confusion and the possibility of devaluing the
epistemology of nursing by implying that the ways of knowing
would lead to specific types of knowledge. Fawcett et al. (2001)
refuted this when they stated, "The diverse patterns of knowing
constitute the ontological and epistemological foundations of the
discipline of nursing. Inasmuch as both patterns of knowing and
theories represent knowledge, and are generated and tested by
means of congruent, yet diverse processes of inquiry, we maintain
that each pattern of knowing may be regarded as a type of theory"
(p. 117).
Exemplars
An example of using Carper's (1978, 1992) ways of knowing
in nursing occurred when the author was working in the Marshall
Islands with a group of nursing students from the U.S. A
Marshallese man from one of the outer islands had been brought
to the hospital for an emergency below the knee amputation of his
right leg. He was septic and for the first few days existed on
intravenous (IV) fluids. After his condition improved from very
critical to critical, he demanded that the IV be removed. The
patient's doctor ordered Gatorade to replace the fluids and
electrolytes formerly provided by the IV. The patient refused to
drink it. Upon informing the author of their patient's refusal to
drink the Gatorade, the students were instructed to ask the man's
wife to give him some water from the coconuts she had in the
room {esthetics). The students were shocked and asked for
rationale for this direction. During a prior experience in the
Marshall Islands the author had been told about coconut water
being used during the Second World War when no IV fluids were
available {empirics). After this episode, a special relationship or
bond developed between the Marshallese man, who wanted to be
in charge of his situation, and the author, who he allowed to take
charge when necessary {personal).
Another poignant example was provided by a nurse from
Cameroon. Shortly after graduation, the nurse was assigned to the
pediatric ward of the provincial hospital. One of the nurse's
assignments involved care of a two year old girl with cleft lip and
palate. The girl's mother remained with her at the hospital while
the father went to find money for the girl's surgery, which was to
The Journal of Theory Construction & Testing -10-
be done by a visiting maxillofacial surgeon. After about two weeks
the nurse noticed that neither the mother nor the girl had enough
food to eat. In Cameroon food is purchased by the family for the
patient; it is not provided as part of hospitalization. When the
nurse mentioned this to the mother, she indicated that the little
money the father was able to leave with her was gone. The nurse,
recognizing the need for the girl to be healthy for her upcoming
surgery and having some extra money, gave it to the mother
{ethics). Several weeks after surgery, on the day of the girl's
discharge, the mother approached the nurse saying she had
nothing to give to the nurse but her heartfelt thanks, not for the
money, but for not avoiding her daughter and for treating her as
the child she was, not some disfigured creature to be avoided
{personat).
Other examples of the ways of knowing in nursing may be
found in publications such as the Art ofNursing: Expressions ofthe
Creative Art in Nursing (Wendler, 2002 ) and Chicken Soup for the
Nurse's Soul: 101 Stories to Celebrate, Honor, and Inspire the
Nursing Profession (Canfield, Hanson, Mitchell-Autio, &
Thieman, 2001).
CONCLUSION
The ways of knowing in nursing appear straightforward
when first encountered, but when critically examined, they are as
complex as the discipline of nursing itself. The authors cited have
added great depth and breadth to the understanding of the
concept of the ways of knowing in nursing, yet Carper's explica-
tion continues to delineate the epistemology of the profession of
nursing. Some aspects of nursing care are tacit and not easily
communicated, but nurses incorporate Carper's four ways of
knowing as they provide care helping people of all ages attain,
maintain, or regain health.
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Patricia E. Zknder, PhD, RN, is Associate Professor and
-Assistant Dean RNsto BSN Program atViterho University th La
Crosse, Wisconsin_^4601,
Vblume 11, Number 1