What to turn a unity into a multiplicity— choices must the nurse make in order to so it is with the human being to know another self in an authentic relation whom I say You.
These choices raise fundamental ques- tialist to the cybernetic, from the idea of an tions about morally right and wrong action information processing machine to one of in connection with the care and treatment of 17 p a many splendored being. Empirical seem to result in contradiction. The discipline of any given individual.
Both goals and actions involve choices made, Ethics: The Moral Component in part, on the basis of normative judgments, Teachers and individual practitioners are both particular and general. Moral choices to be made must a state in which they are independent. Each of these separate but none of them alone should be considered but interrelated and interdependent funda- sufficient.
Caring for another requires it is valid, the kinds of data it subsumes, and the achievements of nursing science, that is, the methods by which each particular kind of the knowledge of empirical facts systemati- truth is distinguished and warranted. Holt, new and unsolved questions.
These new and Rinehart and Winston, With each change in the 8. Springer require looking for different points of contact Publishing Co. The World Publishing Co. Harper and Row, Book of Esthetics, 3rd ed. Remember me on this computer. This website uses cookies to improve your experience while you navigate through the website. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are as essential for the working of basic functionalities of the website.
We also use third-party cookies that help us analyze and understand how you use this website. Although it may be difficult to stretch our minds back to why that might have been, it is instructive to consider that Howard Gardner's book, Frames of Mind: The Theory of Multiple Intelligences , was not published until In a somewhat similar manner, Edward de Bono's Six Thinking Hats , which was first published in , was an idea that was originally conceived of as a way of understanding different styles of business decision making but also found an audience in applied disciplines such as nursing Cioffi, Using the heuristic of differently coloured hats, de Bono identified six characteristic approaches to working through complex challenges, each with potential merits towards a particular decision and each with its own set of limitations.
Thus, in Carper's time, the wider scholarly community was only just beginning to push past a more global understanding of knowledge and knowing within an applied discipline and to see it as a multifaceted and dynamic kind of activity. Her thinking was therefore quite provocative for its time, and it is understandable that it had such a profound and lasting impact.
We began to see creative approaches, such as personal stories, criticism of works of art, principles and codes, dialogic justifications, appreciative inspiration being used to teach the thought processes of nursing and to enter into our lexicon as frames of reference for nursing knowledge.
Although there was very little challenge to the basic four ways of knowing, scholars began to augment them, extending theorizing into other possible options to explain the complexity that is excellent thought within nursing. For example, in , Munhall proposed that knowing could lead to closure based on false confidence in one's own interpretation. It was an essential competency, from their perspective, if nursing was to focus its attention on developing an awareness of social problems and taking action to create social change.
Carper's understanding of this form of knowing was that it was the most difficult to master and teach and also the most essential to understanding the essence of patient care p. In this way, it would seem that the original notion of personal knowing, which was intended as a critically reflective approach to knowing and understanding one's role in the clinical encounter and in relational practice, is being taken up within certain segments of the profession in support of ideas that extend well beyond that initial context.
And this becomes especially concerning in the context of an intellectual climate within which personal knowing is understood to reference holistic thinking and, therefore, to uncritically trump the other components. As Smith argued in , because all knowing is personal knowing, personal knowing ought to have a central and primary place in nursing thought , p.
In , Silva, Sorrell and Sorrell questioned the application of Carper's four ways of knowing, pointing out that they had come to address all aspects of both knowing epistemology and also being ontology in the discipline. Because personal knowledge is fundamental, what is contained in personal knowledge takes on the cache of legitimacy as valid epistemology and even ontology for the discipline.
Although Benner's early work in particular has helped us appreciate that pattern recognition is a basic mechanism for advancing one's knowledge from novice to expert in the practice application domain, presumably we would not accept the corollary that all patterns that develop are evidence of expert thinking.
Consider, for example, what we know all too well about stereotypical patterns that can be discerned on the basis of prior conditioning or selective attention, such as might derive from ingrained theoretical or attitudinal biases. Thus reflecting on both the intention and the subsequent application of the idea of personal knowing, it becomes important to put some thought towards how vulnerable our discipline's core values ought to be in relation to the changing external forces that may exert an influence on the reflective capacity of individual nurses.
It is widely recognized within the nursing philosophical community that a healthy critique of empirical science as the predominant form of credible knowledge in the health field is both useful and appropriate. The capacity to conceptualize and enact care that is individualized, which can be seen as the antithesis of standardized practice, has a long history as a central feature of nursing's distinctive mandate Liaschenko, To illustrate, we might look to the worrisome wave of antiscience showing up in nursing internationally Garrett, Do we have disciplinary clarity on what the boundary really is between a substantive logical assertion made on behalf of the profession and a spurious idiosyncratic claim based entirely on belief or opinion?
Or, in a climate of trying to be respectful of diverse perspectives, have we lost the foundational core that keeps our profession grounded? In a similar vein, as I referenced earlier, we seem to be seeing hesitation in some sectors of nursing and within nursing organizations to step into policy issues in which a clear nursing voice supported by established evidence would seem entirely appropriate if we had confidence in that moral core.
Especially in politically explosive times, perhaps because they expect some diversity in opinion among individual members of the profession, we start to see our professional nursing bodies shying away from strong policy advocacy on the very issues that would seem to most benefit from a coherent nursing perspective.
All of these issues are matters in which there is a history of strong and powerful nursing advocacy and which are easily justified by virtue of our knowledge of the social determinants of health and the mandate nursing has with respect to the dignity of all persons.
Carper's idea of personal knowing was never intended to justify the correctness of individual nursing opinions and beliefs; rather it was proposed as a way of thinking about the kind of relational authenticity that that nursing excellent inevitably requires within the multiplicity of encounters in the practice context. It acknowledged that the building of this skill set draws into the nursing knowledge equation ideas from multiple sources including one's own experiences, ideas and values; it was never meant to condone relying on them exclusively, any more than using evidence in practice should imply allowing that which has been convincingly quantified in populations to unilaterally dominate decisions on behalf of individuals.
And it was never meant to legitimize prioritizing a personal idea or bias over a coherent grounding in nursing knowledge. If we reflect back on the ideas from Carper, Gardner and de Bono, what we were seeing in this movement was a way of addressing the complexity of excellent thinking—confirming that the capacity to see a situation from multiple perspectives offers us the opportunity to approach higher quality, more robust and better informed decisions. Science denial, therefore, is clearly inconsistent with this ideal.
What is consistent with the intended purpose is being in possession of a solid understanding of the science and yet coming to a reasoned determination on the basis of other patterns of knowing that it does or does not apply to the particular case I have before me at this juncture in time. In order to keep the multiple intelligences and differing patterns of knowing in perspective, and in a balanced relationship with one another, nursing must have the capacity to uphold a set of shared core values that constitute its professional and disciplinary angle of vision.
Arguably, we once had such convictions, and perhaps the forces of social change have weakened our collective confidence that these remain relevant. We are also growing more comfortable with interdisciplinary learning and training opportunities in which core nursing disciplinary knowledge may not feature at all in curriculum. However, without solid grounding in what it means to be a nurse, and what serve as core disciplinary values, a new generation of nurses may be increasingly at risk for confusion over what differentiates the ideas we hold as individuals and the ideas that we claim to share.
As a case in point, I turn to the example of Medical Assistant in Dying MAiD in Canada as new development that has significantly challenged the profession. Historically, most of our nations have upheld prohibitions against anything that might hasten death, and nurses have walked a fine line to ensure that our comfort measures were in balance with that prohibition. However, in Canada, as in a number of other nations, the context of what this might mean it is evolving. In implementing this, Canadian nurses have drawn upon their experience with abortion, in which the profession has never faltered in its policy commitments in support of a woman's right to choose, even as it has made room for individual nurses who may have difficulty with such practices for personal reasons.
In the MAiD context, nursing organizations have been consistently strong in their advocacy for a patient's right to a preferred death and to systems that respectfully and expertly support that, even as our care systems manage the reality of differing personal perspectives.
Interestingly, this nuanced perspective is also exemplified in Canada's only faith based nursing education program at Trinity Western University. That program secured its approval to provide nursing education by demonstrating a commitment to values clarification consistent with provincial nursing practice standards.
The faculty have become exemplary role models of high quality critically reflective practice knowledge on behalf of nursing. Individual students may enter that program with firm ideas, biases and religious convictions, but they leave their educational programs knowing how to ensure that such views never inflict harm on their patients. As I read some of this work, I interpret authors as taking the argument in an entirely different direction, endorsing specific religions as the appropriate source of core nursing values.
To illustrate:. Explicating spiritual knowing as a pattern of knowing in nursing is an important contribution, given that nursing has been grounded in a wholistic view of the human being, accounting for the spiritual nature of human beings from a Christian call to service.
If we claim that nursing does not in and of itself have core values, then we expose ourselves and our work on behalf of this discipline to the same kinds of forces that made those strong nursing leaders I mentioned earlier uncomfortable addressing racism in the classroom.
If we can agree to stand firm on the idea that nursing does constitute core values, I think we are capable of being a force for enacting the social mandate that our discipline has always claimed. To me, this exemplifies the existence of core nursing values as a fundamental reason that multiple ways of knowing, including personal knowing, can work in the everyday practice world. We come to know those core values—to engage with them, reflect on them and wrestle with them—through the dialectic of our disciplinary theorizing and philosophical work.
In , in conjunction with the World Health Organization's declared Year of the Nurse and Midwife, we may have a once in a generation opportunity to demonstrate to the broader world what nursing is and what it stands for. In justifying such an international focus, Director General Dr. Such strong positions on issues of equity, access and public health policy around social determinants of health are unquestionably values driven initiatives. One hopes that nursing can fully capitalize on this game changing opportunity in a manner that showcases not only the technical competencies it brings to a care delivery system but also, and as importantly, the powerful set of core values it brings to health advocacy and public policy.
Personal knowing out of context can be dangerous. Within the context of nursing theoretical or epistemological frameworks and philosophies that guide us to attend to the multiplicities of factors involved in determining action, and—in the context of the core values that are an inherent part of all of those frameworks—personal knowing can spur us into action, provide us with the nuanced capacity to engage in difficult circumstances and help us make creative and strategic choices in how each of us can act to mobilize our collective social mandate.
If we accept the argument that a shared set of values is consistent with nursing's social mandate, then these might be some of its manifestations: that no person should ever be denied health service by virtue of religion, skin colour, sexual or gender orientation, politics and even economic status; that it is unacceptable to treat anyone in an undignified manner, regardless of that person's capacity to engage in with us in a manner that shows dignity; that the smallest, most marginalized vulnerable voice in our society would be supported to speak out and receive the care that is needed and deserved; and that every person who enters into the care of a nurse should be able to feel confident in the knowledge that the care will be culturally safe and respectful.
In this context, we need the nursing philosophy community to be strong and relevant, and to fully engage with the advocacy arm of nursing to express and enact the core values that underlie those kinds of commitment.
While personal knowing is and will continue to be an important experiential aspect of our collective knowledge work, we need to understand it in its full complexity such that we can detect and act on its abuses. Some open questions were asked to complete the observation. The researcher used several strategies to ensure that the findings are trustworthy. Data collection and analysis were simultaneously done during 20 months for long observation and floating in the data.
Two nursing faculty members who were experienced in qualitative studies reviewed the findings, transcriptions of interviews, observations, and coding to obtain credibility via peer checking. The participants signed a written informed consent letter.
The principles of data unanimity and confidentiality were observed and the participants were informed that they could leave the study at any stage. Finally, 19 Nurses with different characteristics were interviewed [ Table 2 ]. Data analysis indicated that nurses, sometimes affected by contextual conditions such as discriminatory beliefs and undesirable individual characteristics, eliminate one or more patterns of knowing and always aesthetic pattern, most of ethical pattern and to a lesser degree, empirical and individual patterns.
The result of such care is to create an ugly image of the nursing profession and this ugliness will be evident to all.
Five categories of omission of some patterns of knowing include: A Omission of scientific principles, B Omission of therapeutic relationship, C Omission of social justice, D Omission of ethics, and E Omission of flexibility, in a hierarchical pattern [ Table 3 and Figure 1 ].
Omission of scientific principles: The findings of the study indicated that the omission of scientific principles or empiric knowledge leads to unscientific care, including negligence in caring and error in caring.
I cannot describe what the patient went through afterwards…. Omission of therapeutic connection: The findings of the study indicated that the omission of therapeutic relationship or refusal to use therapeutic use of self is instantiated with providing care without positive and therapeutic connections.
There are three sub-categories in this category including referring patients to others, caring reluctantly and avoiding, and mechanical care. Similarly, the other nurses asked him to do some other things that are not considered part of his responsibility. Observation in urology ward. I noticed that his Blood Sugar BS was not checked and nobody has attended him throughout a whole work shift.
Omission of social justice: The findings indicated that the omission of social justice is a kind of omission of emancipatory pattern. There are three sub-categories in this category, namely, discrimination based on social level of patient, patient's feedback and others' commendation.
Omission of ethics: The data analysis of the study confirmed that the omission of ethics would also occur along with other omission of the patterns of knowing. There are ten sub-categories in this category including stigmatization, aggressiveness, mimicking, backbiting, sleep induction, concealing, pretending, ignoring the patient's right to be aware, and retaliating and disregarding other ethical principles. The nurse disconnected the serum, threw it into the trash bin, while shouting loudly and angrily: is it over?
Do you have anything else to say? I don't know what to do with them… Colleagues confirmed and laughed. My colleague kicked his leg and told him: do you want to beat me?
My colleagues don't consider that patients are more sensitive to noises during the night…. Omission of flexibility: The omission of flexibility will also occur along with other omissions of patterns of knowing.
There are three sub-categories in this category, including inflexibility in dealing with patient values, inflexibility in law enforcement and inflexibility in communication with patients. She was praying before the procedure. It cannot help you. The patient became sad and lowered her head. All the four nurses were sitting at the nursing station but none of them answered him.
The old man called repeatedly. Finally, staff nurse told: oops! Again, bed no. And then, he ordered the nursing students to visit him. The first sub-category related to the omission of some patterns of knowing was the omission of scientific principles. According to the findings, omission of scientific principles appeared as negligence or error. Negligence in caring is related to misunderstanding the patient or feeling no sympathy and it appears as neglecting patients physically or emotionally.
Missed nursing care, which is an error or omission of a care, for example, educating the patient,[ 36 ] is a serious problem in hospitals all around the world, which leads to a lower-quality care and dissatisfaction in patients. The findings of the study revealed the omission of therapeutic relationship accompanied by omission of personal knowing. Although the findings of a meta-ethnography indicated that a suitable relationship between nurse and patient improves health and recovery and most importantly, it results in emotional, mental, and social wellness in the patient.
According to the findings, omission of social justice is rooted in the omission of emancipatory pattern. That is, nurses might discriminate between patients with low and high socioeconomic status. The finding of another study also revealed that patients with lower socioeconomic, cultural or education status might be subject to care discrimination. Along with this finding, the results of another study showed that women patients with lower socioeconomic status and immigrants were more discriminated than the others.
Nowadays, scientific and technological developments highlight the need to pay more attention to ethics in nursing care. A study[ 48 ] indicated some of personal characteristics such as believing in God as a supervisor of man's actions, enable nurses to stand the work and clinical care pressure.
However, due to the lack of humanistic and ethical beliefs, some nurses blame bad work condition, lack of motivation, and fatigue for their mistakes and poor performance. Carper[ 4 ] argues that ethical pattern indicates the position of ethical codes which dictates what decision is ethical or unethical.
Empathy, sympathy, respecting patients as human beings, along with technical competencies all affect the quality of clinical care. On the contrary, treating patients with indifference and humiliating them are instances of low-quality care,[ 43 ] which is in contrast with holistic care. Holistic care encompasses all the aspects of patients, their effects on the treatment process, happiness, and patient's satisfaction. Holistic care is more than a humanistic care and emphasizes integrity of body, brain, and soul as a unit and an energy field.
Omission of flexibility is another main categories of the study. Flexibility is not a pattern of knowing. Rather, it is a core variable and makes interrelationship between the patterns of knowing; Therefore in the situations of the omission of some patterns of knowing, nurses do not apply flexibility and are rigid when dealing with patients' values, law enforcement and communicating with patients, although findings of a study showed flexibility in meeting time leads to satisfaction of patients and their families in ICU.
Aesthetic pattern or art is indeed the essential nature of nursing that creates artistic moments. Such moments are the outcomes of an actual and creative connection between nurses and patients and everything that happens in such a situation is valuable. As to limitations, it is notable that the abstract nature of the subject made it hard for nurses to perceive some of the concepts. In such cases, further detailed explanations are provided to clarify the concepts concealed in questions.
The aim of this study was to explore the role of patterns of knowing in the formation of uncaring behaviors. The findings indicated that nurses might eliminate one or more patterns of knowing under the effect of their discriminative beliefs and undesirable characteristics. In such situations, the nurse has no flexibility and eliminates the aesthetic pattern along with the other patterns of knowing. Removing scientific principles, therapeutic use of self, ethical principles, and flexibility as the core variables of this process will lead to uncaring behaviors such as caring errors, avoidance, discrimination, aggressiveness, and inflexibility.
Uncaring behaviors are quite visible for others such as patients and colleagues. The findings serve as a theoretical ground for future studies in order to develop questionnaires for measuring the omission of some patterns of knowing. This paper is a part of doctoral dissertation under the code number and was supported from Iran University of Medical Sciences.
We appreciate the departments of education and research, and all the nurses who participated and helped the study. National Center for Biotechnology Information , U. Iran J Nurs Midwifery Res. Published online Oct Author information Article notes Copyright and License information Disclaimer. Address for correspondence: Dr.
0コメント