34
A ContemporaryNursing Process
The (Un)BearableWeight of Knowingin Nursing
■ Rozzano C. Locsin, RN, PhD, FAAN■ Marguerite J. Purnell, PhD, RN, AHN-BC
NEW YORK
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Rozzano C. Locsin, RN, PhD, FAANRozzano C. Locsin, RN; PhD, FAAN is Professor of Nursingat Florida Atlantic University’s Christine E. Lynn College ofNursing in Boca Raton, Florida. He holds a masters degreefrom Silliman University, and a Doctor of Philosophy inNursing from the University of the Philippines. Understand-ing “life transformations and transitions in the human healthexperience” defines his nursing research, articulatingknowing persons as whole through technology, caring, andnursing. Dr. Locsin published his middle-range theory enti-tled, Technological Competency as Caring in Nursing in 2005.Advancing Technology, Caring and Nursing published in 2001and Technology and Nursing Practice published in 2007 arehis two other books. Dr. Locsin’s international work includesprogram developments in nursing education in Uganda,Thailand, and the Philippines. His national and internationalprojects are on the topics of holistic nursing, care of olderpersons, and alternative and complementary therapies. Hewas a Fulbright Scholar to Uganda, a recipient of FulbrightAlumni Initiative Award and is a Fulbright Senior Specialistin Global Health and International Development. In 2003 hereceived the prestigious Edith Moore Copeland Excellence inCreativity Award from Sigma Theta Tau International HonorSociety of Nursing. In 2006, he was elected Fellow of theAmerican Academy of Nursing.
Marguerite J. Purnell, RN, PhD, AHN-BCMarguerite J. Purnell, RN; PhD is Assistant Professor ofNursing at Florida Atlantic University’s Christine E. LynnCollege of Nursing. She holds a masters degree from FloridaAtlantic University and a Doctor of Philosophy in Nurs-ing from the University of the Miami, Miami, Florida. Sheis board certified in Holistic Nursing. Dr. Purnell’s programof research is centered on intentionality, caring, and ener-getic healing in nursing practice. Her current leading edgeresearch focuses on the creation of optimal healing envi-ronments with stored intention. An expert nurse educator,Dr. Purnell has published broadly on the topics of caringin Nursing, particularly on the valuing of caring in nursingeducation. Her Model of Online Nursing Education wasdesigned for virtual environments and is grounded in caringintention as the organizing framework. She has publishedwidely on other topics on nursing including the influences of
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technologies in Nursing.As co-editor of this book, Dr. Purnelldeclares her passion for communicating nursing in quintes-sential ways for the education of contemporary nurses, andfor developing the ontologic thread of informed caring tosupport and affirm nurses of the future.
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A contemporary nursing process : the (un)bearable weight ofknowing in nursing / [edited by] Rozzano C. Locsin, Marguerite J.Purnell.
p. ; cm.Includes bibliographical references.ISBN 978-0-8261-2578-11. Nurse and patient. 2. Nursing—Philosophy. I. Locsin,
Rozzano C., 1954– II. Purnell, Marguerite J.[DNLM: 1. Nurse-Patient Relations. 2. Nursing Process. WY
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Contributors
ForewordAnne Boykin
PrologueRozzano C. Locsin and Marguerite J. Purnell
Acknowledgments
Section 1: Philosophical, Theoretical, and HistoricalPerspectives of Knowing
Chapter 1. Phoenix Arising: Synoptic Knowing for a Synoptic Practice of Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Marguerite J. Purnell
Chapter 2 Transcending Boundaries: Nursing—A Synoptic Discipline? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Savina O. Schoenhofer
Chapter 3 “With the Very Best of Intentions”: The Developmentof Nursing Process as a Way of Knowing . . . . . . . . . . 31Lynne M. Dunphy
Chapter 4 Inspired Knowing in Nursing: Walking on Moonbeams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Pamela G. Reed
Chapter 5 Consciousness and Knowing: The Patterningof the Whole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73W. Richard Cowling III and Elizabeth Repede
Contents
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Table of Contents ixChapter 6 Evidence, Knowledge, and Wisdom: Nursing Practice
in a Universe of Complexity and Mystery . . . . . . . . . 99Gail J. Mitchell
Chapter 7 Knowing Persons as Whole: Bearing Witness to Unfolding Mystery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123William K. Cody
Chapter 8 Holistic Knowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Marlaine C. Smith
Chapter 9 Unknowing: Towards the Understanding of Multiple Realities and Manifold Perceptions. . . . . . . . . . . . . . 153Patricia L. Munhall
Section II: Processes of Knowing in Nursing: PracticePerspectives
Chapter 10 Knowing Patients’ Bodies: Nurses’ Bodywork . . . . . 175Zane Robinson Wolf
Chapter 11 Journeying with Linda: A Narrative Approach to Practice and Research . . . . . . . . . . . . . . . . . . . . . . . . 205Christopher Johns
Chapter 12 Caring for “Not-So-Picture-Perfect Patients”:Ethical Caring in the Moral Community of Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225Marian C. Turkel and Marilyn A. Ray
Chapter 13 Decision Making and Knowing in Nursing:The Essentiality of Meaning . . . . . . . . . . . . . . . . . . . 251Susan K. Chase
Chapter 14 An Exquisite Knowing of Children . . . . . . . . . . . . . . 281Bernie Carter, Marie Marshall, and Caroline Sanders
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Chapter 15 Knowing Persons With Disabilities: Nurses Illuminate Difference in a Natural Light . . . . . . . . . . . . . . . . . . . 305Donna Carol Maheady
Chapter 16 Clinical Knowing in AdvancedPractice Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329Ruth McCaffrey
Section III: Influences of Technology on Knowing inNursing
Chapter 17 Vision, Technology, and the Environmentof Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357Alan Barnard
Chapter 18 “Painting a Clear Picture”: Technological Knowingas a Contemporary Process of Nursing . . . . . . . . . . 377Rozzano C. Locsin
Chapter 19 Knowing the Person and Technologyas Medium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395Marilyn Macdonald
Chapter 20 Rapture and Suffering With Technology in Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415Rozzano C. Locsin and Marguerite J. Purnell
Section IV: Knowing the Person Through Lenses ofCulture and Community
Chapter 21 Coming to Know Community:Going to the Mountain . . . . . . . . . . . . . . . . . . . . . . . . 429Charlotte D. Barry and Shirley C. Gordon
Chapter 22 Knowing the Patient and Being a Good Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445Samantha M. C. Pang, MichikoYahiro, and HelenY. L. Chan
x Table of Contents
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Chapter 23 Continuous Knowing of Patients:The Japanese Nursing Perspective . . . . . . . . . . . . . . 463Yukie Takemura and Katsuya Kanda
Chapter 24 Influence of Culture on Knowing Persons . . . . . . . . 481Carolina Huerta and M. Sandra Sanchez
Epilogue: Moving Forward in a Contemporary Practice of Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505Marguerite J. Purnell and Rozzano C. Locsin
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Table of Contents xi
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Anne Boykin, RN, PhD Dean and Professor Florida Atlantic UniversityChristine E. Lynn College of Nursing Boca Raton, Florida
Savina O. Schoenhofer, RN, PhD Professor of Nursing Department of Graduate Nursing Alcorn State UniversityNatchez, Mississippi
Lynne M. Dunphy, PhD, ARNPProfessor of Nursing and Routhier Chair of Practice At the College of Nursing Universityof Rhode Island Kingston, Rhode Island.
Pamela G. Reed, PhD, RN, FAANProfessorUniversity of ArizonaCollege of Nursing Tucson, Arizona
W. Richard Cowling III, RN, PhD, AP,RN-BC, AHN-BCProfessor and Director, PhD Program Editor, Journal of Holistic Nursing School of Nursing University of North Carolina GreensboroGreensboro, North Carolina
Elizabeth Repede, PhD(c), FNP-BC,CMHSchool of Nursing University of North Carolina GreensboroGreensboro, North Carolina
Gail J. Mitchell, RN, PhD Associate Professor School of Nursing,York UniversityMidland, Ontario, Canada
William K. Cody, RN, PhD, FAANDean and Professor Presbyterian School of Nursing at Queens UniversityCharlotte, North Carolina
Marlaine C. Smith, RN, PhD, AHN-BC,FAANProfessor and Associate Dean for Academic Programs Helen Karpelenia Persson Eminent ScholarChristine E. Lynn College of Nursing Florida Atlantic UniversityBoca Raton, Florida
Patricia L. Munhall, EdD, ARNP,NCPsyA, FAANFounder and President, International Institute for Human Understanding Miami, Florida
Zane Robinson Wolf, PhD, RN, FAANDean and Professor School of Nursing and Health SciencesLaSalle UniversityPhiladelphia, Pennsylvania
Christopher Johns, RN, PhD, PACTComplementary Therapist andProfessor of Nursing University of Bedfordshire Bedfordshire, UK
Contributors
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Marian C. Turkel, RN, PhD Director, Professional Nursing PracticeAlbert Einstein Medical Center Philadelphia, Pennsylvania
Marilyn A. Ray, RN, PhD, CTN Professor Emeritus Florida Atlantic UniversityChristine E. Lynn College of Nursing Boca Raton, Florida
Susan K. Chase, EdD, ARNP, FNP-BC Professor and Assistant Dean for Graduate Programs Christine E. Lynn College of Nursing Florida Atlantic UniversityBoca Raton, Florida
Bernie Carter, PhD, PgC, PgC, BSc,RSCN,Professor of Children’s Nursing School of Nursing and Caring SciencesUniversity of Central Lancashire Preston, United Kingdom
Marie Marshall, BSc (Hons), DipHE,RSCN, RGN, EN Children Community Specialist PractitionerCentral Manchester and Manchester Children’s Hospitals, NHS Stockport, United Kingdom
Caroline Sanders, RSCN, RN, BSc (Hons), PgD Psychosexual Health Consultant Nurse, PaediatricUrology/GynaecologyRoyal Liverpool Children’s Hospital NHS TrustAlder Hey, United Kingdom
Donna Carol Maheady, EdD, ARNPAdjunct Assistant ProfessorChristine E. Lynn College of Nursing Florida Atlantic UniversityBoca Raton, Florida
Ruth McCaffrey, ARNP, DNP Associate Professor of Nursing Christine E. Lynn College of Nursing Florida Atlantic UniversityBoca Raton, Florida
Alan Barnard, RN, BA, MA, PhD Senior Lecturer School of Nursing Queensland University of TechnologyVictoria Park Road, Kelvin GroveQueensland, Australia
Marilyn Macdonald, RN, PhD Assistant Professor School of Nursing Dalhousie UniversityHalifax, Nova Scotia, Canada
Charlotte D. Barry, RN, PhD, NCSN Associate Professor Christine E. Lynn College of Nursing Florida Atlantic UniversityBoca Raton, Florida
Shirley C. Gordon, RN, PhD Associate Professor Christine E. Lynn College of Nursing Florida Atlantic UniversityPort St. Lucie, Florida
Samantha M. C. Pang, PhD, RN Professor and Head School of Nursing The Hong Kong PolytechnicUniversityHung Hom, Kowloon, Hong KongSAR, China
Michiko Yahiro, MSN, RN PhD student School of Nursing The Hong Kong PolytechnicUniversityHung Hom, Kowloon, Hong KongSAR, China
Contributors xiii
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Helen Y. L. Chan, BSN, RN PhD student School of Nursing The Hong Kong PolytechnicUniversityHung Hom, Kowloon, Hong KongSAR, China
Yukie Takemura, RN, PhD Vice Director of Nursing The University of Tokyo Hospital Bunkyo-ku, Tokyo, Japan
Katsuya Kanda, RN, PhD Professor of Nursing AdministrationGraduate School of Medicine Department of Nursing AdministrationThe University of TokyoBunkyo-ku, Tokyo, Japan
Carolina Huerta, RN, EdD Chair and Professor of Nursing Department of Nursing College of Health Science and Human ServicesUniversity of Texas–Pan AmericanEdinburg, Texas
M. Sandra (Sandra) Sánchez, RN, PhDAssociate Professor of Nursing Department of Nursing College of Health Science and Human ServicesUniversity of Texas–Pan AmericanEdinburg, Texas
xiv Contributors
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Foreword
At the heart of a thoughtful practice process of nursing iscoming to know persons. The realization that nursing cannottruly take place without the intentional and knowing engage-ment of the nurse with the one nursed is critical to advancingknowledgeable practice. Much has been written about knowingin nursing, initially stimulated by Carper’s germinal study onfundamental patterns of knowing. Since then, scholars haveidentified and described other ways to come to know personsfrom a variety of perspectives. Nonetheless, these efforts toknow are just beginnings—a place from where we might beginto reach higher, deeper, and broader.With this declaration, thisbook offers perspectives from contemporary nursing scholarsfor knowing persons—from the abstract reaches of philosophyto the realities of contemporary practice where the rules of con-vention may not fit, and where nurses are challenged to knowthemselves in order that they may truly know those nursed.
As a unity of scholarship, the book constitutes an activetext for students to rise above the confines of the rudimen-tary traditional Nursing Process more popularly known as“APIE”—assessment, planning, intervention, and evaluation toa complex,creative,relational,and expert practice that extendsacross venues and specialties and is grounded in postmod-ernist/human science viewpoints. Indeed, the philosophicalgrounding of the traditional nursing process in positivism/empiricism is perpetuated by the notion that APIE is the sci-entific method, and therefore thinking by nurses outside ofthis linear process is discouraged, devalued, and contradictoryto the established and popular health care practice process.
The goal of the book is to illuminate knowing of personsas a contemporary, human-centered, distinctive process ofNursing, in which knowing the person is the unfolding of thevalue of the nursed and nurse.The general theme of the book,transcending the confines of the traditional nursing process, is
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simply “knowing persons.” It promotes the realization of waysof knowing other than those solely grounded in empiricist/objectivist viewpoints. The need to re-think the TraditionalNursing Process is emphasized, as is the need to re-envisionand shift the focus of knowing the person as object, to know-ing person as person. In this transformative and transcendentprocess of nursing with multiple dimensions for practice, boththe nurse and the one nursed are honored as whole.The nurseis freed to nurse in a meaningful and creative way.
Locsin and Purnell believe that the postmodernist/human science views provide philosophical underpinningsthat transform one’s understanding of the traditional nursingprocess to a contemporary process of nursing that is of andwith the person. Such a contemporary process of nursing isexpressed uniquely in diverse ways. Maintained in this dis-tinction is the understanding that the context for nursing isthe nursing situation which Boykin and Schoenhofer (2001)describe as “those shared lived experiences in which thecaring between the nurse and nursed enhances personhood”(p. 17). Fundamentally occurring in this nursing situation iscontinuous, moment-to-moment knowing of persons as car-ing. In knowing the person, the nurse intentionally focuseson coming to know person, on hearing the calls for nursing,and on creating unique and meaningful caring responses.
Today there are many challenges facing health caresystems.I believe the most important of these is the call to createmodels of care which nurture, support, and celebrate nursing asa discipline and profession; Models of care which understandand appreciate that to nurse, the nurse must be fully engaged inthe human situation… …to nurse, the person(s) nursed must beknown.Inthiscompendium,LocsinandPurnell invite thereaderto let go of the traditional nursing process as having served andoutgrown its purpose, and to embrace a contemporary, substan-tive process of nursing grounded in knowing persons as partici-pants in their care instead of being objects of our care.
Anne Boykin, RN, PhD Dean and Professor
Florida Atlantic UniversityChristine E. Lynn College of Nursing
Boca Raton, Florida
Boykin, A., & Schoenhofer, S. O. (2001). Nursing as caring: A model for transforming practice. Sudbury, CT: Jones & Bartlett.
xvi Foreword
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Prologue
The idea of this book evolved out of a decade or more ofcollaborative and pithy conversations over a steady ritualof afternoon tea, where we ruminated on subjects near anddear to us in nursing. The notion of the traditional nursingprocess as an impediment to reflective and thoughtful prac-tice arose repeatedly. The institutionalization of the nursingprocess taught in most schools of nursing, along with itsrequired use in hospital settings, was a focus of concern tous. In our discussions, we returned again and again to theidea that nurses appear to be programmed into a type ofthinking that produces cyclical, prescriptive, and predictivepractice with the use of the Traditional Nursing Process(assessment, planning, intervention, and evaluation) as thestandard for nursing practice.
Indeed, the philosophy of the traditional nursing processis grounded in positivist and empiricist thoughts, and is per-petuated by the notion that the APIE is the scientific methodand is therefore justified in its adoption as the practice norm.Persons are viewed as collections of parts, a process thatbegins when medical consultation is first sought.The processis perpetuated in health care institution systems where mostnurses practice. Thinking outside the box, away from the lin-ear process, is discouraged, devalued, and derided as contra-dictory to the scientific system.
In contrast, a transformative and transcendent processof nursing with multiple dimensions for practice honors boththe nurse and the one nursed as whole. This transcendentprocess opens the way for co-creating mutual relationshipsand for affirming each other’s hopes and dreams of healthand well-being. This understanding advocates for, andindeed, demands the illumination of alternative views whichadvance contemporary nursing practice. The impetus for
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development of this book was borne out of this underlyingmoral stance.
As an overarching concept, knowing persons, the(un)bearable weight of practicing nursing encompassesthe burden of reconciling two very different perspectivesin nursing: the institutionalized processes for addressingproblem-oriented nursing, and the processes of knowingpersons that arise from a human science perspective. Canthese views ever be reconciled? Is there a way to bring themtogether in a harmonious co-existence?
Currently, there exist various traditionally oriented pro-cesses of nursing, most of which are viewed from perspectivesof humans that target wholeness as being made up of parts,and of nursing as making the person whole by completing theparts. However, in today’s views of contemporary processes ofnursing, we witness a different philosophical lens of humanscience that is becoming more acceptable and commonplace.Even with this growing appreciation, the popularized roteprocess of assessment, planning, intervention, and evaluationcontinues to maintain a highly recognized status as the nurs-ing process, perpetuating its use primarily in clinical areasor in hospital nursing settings in which patient conditions ofhealth are addressed by “disease and illness” care. Despitethis pervasive institutionalization in protocols, software, andhealth care informatics, new and alternative processes ofnursing are steadily being advanced, grounded in nursingphilosophies and theories of nursing. These contemporaryprocesses are framed in an appreciation of the fundamentalvaluing of knowing persons from a human science perspec-tive. They are continually being realized, recognized, andappreciated by practicing professional nurses as valuableand integral to advancing thoughtful nursing practice.
It is the goal of this book to be instrumental to the dis-course concerning contemporary nursing processes withselected topics found crucial to the articulation of a compas-sionate, informed practice process. With this goal, the bookis designed to provoke advancing appreciation of variousprocesses of Nursing grounded in multiple views of nursingpractice. This book embraces the diverse philosophical andtheoretical viewpoints of nurse scholars whose appreciationof persons as unitary beings underpins their understand-ing of professional nursing practice. The anthology of topicsthat comprise the essential substance of the book is directed
xviii Prologue
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toward the identification, description, clarification, and dis-semination of leading-edge processes of nursing groundedin various perspectives within the realm of human scienceand human-centered care.
The book emphasizes the transformation of the processof nursing from a focus on the person as object of care toinstead, the person as a knowledgeable participant in his orher care. In materializing the transcendent idea of nursingcare, the significant thread encompassing these processesof nursing is the nursing practice concept of knowing theperson. This concept is predicated upon the assumption thatprofessional nursing practice is for the purpose of knowingpersons as intimately involved in their own care.
Opportunities are provided in this collection of chaptersfor the practicing nurse to understand knowing the per-son through a lens that is responsive to what matters and isgrounded in what matters: in knowing the person, the nurseaccepts the “witness” role, bearing the weight of knowing theother as person.Each chapter author has created a perspectivethat fosters the description, explanation, and disseminationof a unique and celebratory process of professional nursingpractice.We are indebted to their contribution to this growinghorizon of practice processes that will serve as an inspirationand resource to others.
In each chapter, a view of nursing unfolds as the relation-ship among persons. As such, the focused trajectory is theclarification and illustration of the concept of persons, while“knowing persons” is articulated as a process that keeps evi-dence in synchrony with research data, illuminating nurs-ing care as a deliberative acknowledgment of persons.
Each author has responded uniquely. To illuminate thewriting styles and backgrounds of the contributing authors, abiographical sketch of each is included.
The contributors and coeditors are scholars and prac-titioners of nursing. They recognize that as a discipline ofknowledge and practice profession, Nursing demands a legit-imate understanding of its ontology and epistemology. Howis nursing known, and what are the processes involved inthis knowing? It is the vision of the editors and community ofauthors that the contents of this book will stimulate, motivate,and guide others toward knowing persons as participants intheir care rather than as objects of our care. Knowing theexperiences of the other and calling upon all in our knowing
Prologue xix
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in order to know the other as person is critical to the realiza-tion of a discipline of knowledge and a practice profession.In “knowing person,” Nursing lifts up its voice to advocateand answer meaningfully to society; to those we nurse; and,importantly, to ourselves.
Rozzano C. Locsin, RN, PhD, FAANMarguerite Purnell, RN, PhD, AHN-BC
Coeditors
xx Prologue
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Acknowle
In each journey, there comning is reconsidered andspirit.We have both treasuhave understood their travresponsibilities of teachinwhile giving birth to a thobenefit of Nursing. Additiostruggled to meet challenWe have wondered, how cduring this process? Howstress of meeting deadlinetors to this book, of their cotheir fine, creative works.T
The difficulty in namiwho is important to us, anacknowledge all. In partiAnne Boykin and Dr. Savcolleagues of conscienceunderlying beliefs and valParker’s support has alwaMarilyn “Dee” Ray, Dr. BerLeininger have always exand to seek the highest.
And finally, we thankeditor at Springer, whosprovided laughter and aindeed grateful and offer
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dgements
es an end, a time when the begin-the journey is traveled again in
red and cherished each author andails in trying to balance the myriadg, practice, research, and serviceughtful, scholarly chapter for thenally, our international colleagues
ges of time zones and technology.ould we have cared for them bettercould we have helped alleviate thes? We are proud of all the contribu-nsummate professionalism, and ofheir lights shine.
ng names is that we may miss oned so we say that we would like tocular, we would like to thank Dr.ina Schoenhofer, who have beenin our efforts to stay true to ourues centered in caring. Dr. Marilynys been a steady stream, and Dr.nadette Lange, and Dr. Madeleinehorted us to believe in ourselves
Alan Graubard, our acquisitionse patience and witty rejoinderssense of renewed energy. We areour sincere thanks to all.
Rozzano C. Locsin and Marguerite J. Purnell
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Philosophical,Theoretical,and Historical Perspectivesof Knowing
I
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3
Chapter Overview
Since Carper’s (1978) germinal research was published,nursescholars have critiqued, extended, and sought to reconcilewith practice the four fundamental patterns of knowing thatshe distinguished. This chapter retraces the provenance ofCarper’s (1976) research to its source to reveal two furtherpatterns of knowing that may be similarly derived fromPhenix’s (1964) work: symbolic knowing and synoptic (inte-grative) knowing. Symbolic knowing is the fecund, undiffer-entiated pattern of tacit, unexpressed knowing, valuing, andmeaning from which other patterns arise and are expressed.Synoptic knowing is the pattern in which all patterns aregathered together in unity and fullness. This is the pattern
1PhoenixArising:SynopticKnowing for a Synoptic Practice of NursingMarguerite J. Purnell
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4 Part I: Philosophical, Theoretical, and Historical Perspectives of Knowing
of knowing that answers to the complex, multidimensionalknowing taking place within the caring relationship betweenthe nurse and the one nursed.
Prelude
The mythological phoenix has captured the imagination andwonder of human beings for thousands of years. Chronicledin folklore of diverse and ancient peoples, this noble bird hasappeared in the annals of civilizations flung far across theglobe. The phoenix touches us with wonder. Its life is poi-gnant. In Chinese mythology, the phoenix is a symbol of highvirtue and gentle grace, sipping only upon drops of morn-ing dew. Its venerable life spans 500 years. When the time ofits death draws near, this noble bird collects branches andbuilds itself a large funeral pyre, finally settling sadly onthe wood to draw its last breath and surrender life. As thephoenix bows its head low and slowly begins to die, the woodbursts into flames, consuming the bird until nothing is left.The world holds it breath, until suddenly, transformed outof the ashes, the phoenix arises triumphant, reborn strongerand more beautiful, to live again for another 500 years. It isno wonder that we are drawn to the story of this magnificent,unique creature. The phoenix is a metaphor for courage,transformation, and continuance. The old becomes the new,and knowledge is not lost in change, but becomes change.It is thus we turn our thoughts to nursing as a discipline, tothe uniqueness of its knowledge, to our knowing and how weknow what we know, and to informed courage in surrender-ing to necessary change.
Introduction
Since Carper’s germinal research was published in 1978,nurse scholars have critiqued, extended, and sought toreconcile with practice the four fundamental patterns ofknowing that she articulated. Commentary by more thanone generation of scholars has ranged widely from unques-tioning acceptance and integration to acerbic criticism.Formulaic recitation and description of Carper’s four funda-mental patterns of knowing—personal, empiric, ethical, and
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Chapter 1: Synoptic Knowing for a Synoptic Practice of Nursing 5aesthetic—continues with singular predictability. These pat-terns tend to be applied in a linear, discrete fashion, ratherthan enlightening our knowing practice with a rich, multidi-mensional range of understandings as Carper intended.
While almost every work referring to knowing routinelypays homage in some way to Carper’s unique understand-ing and contribution to nursing knowledge, other scholarshave illuminated uncharted aspects of disciplinary knowingthat simply did not fit well within the four fundamental pat-terns, or did not resonate with their knowing of what wasmeaningful in their practice. Additional ways of knowingsuch as unknowing (Munhall, 1993), sociopolitical know-ing (White, 1995), and women’s ways of knowing (Belenkey,Clinchy, Goldberg, & Tarule, 1986) are now cited routinely intandem with Carper’s original retinue of fundamental pat-terns. Carper rightfully declared then, and other nurse schol-ars continue to follow suit now, that other ways of knowingmay exist. These disclaimers, however, point silently backto a lack of capacity or an inadequacy that is implicit in theoriginal four fundamental patterns: The range and dimen-sions of their domains, in and of themselves, are insufficientto embrace other ways of knowing as they have been discov-ered and added to the knowledge base of nursing.
It is evident that Carper’s four fundamental patternsof knowing, as they were originally presented in her 1978landmark article, provide neither sufficiency nor capacity,given the struggles of nurse scholars to describe their know-ing in nursing phenomena and processes of practice. Carperstressed that each pattern is necessary for achieving masteryin the discipline and that no pattern alone should be con-sidered sufficient or mutually exclusive. The discussion, per-haps, should center on whether all patterns together shouldhave the capacity not only for mutual inclusion, but also forbeing mutually inclusive—a somewhat different premise.
Carper’s unique gift to nursing that explicated and illumi-nated the wide-ranging complexity of knowing and knowledgein practice may be better understood in light of the sourceof her inspiration for these patterns of knowing in Philip H.Phenix’s (1964) Realms of Meaning. This chapter retraces theprovenance of Carper’s (1976) research to reveal two fur-ther realms of meaning that may similarly be found useful inPhenix’s (1964) work: the symbolic and synoptic (integrative)realms. It is important, however, before embarking upon a
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6 Part I: Philosophical, Theoretical, and Historical Perspectives of Knowing
retrospective journey, to examine the influence and concep-tual significance of the language embedded in Carper’s andPhenix’s work.
Linguistic Interplay and Fuzzy Understanding
Knowing and Knowledge. In reflecting upon the multitude ofarticles referring to nurses’ knowing, the rapid exchange inuse between the words knowing and knowledge in the litera-ture compromise clarity in communication of ideas. The twowords knowing and knowledge are different parts of speech(gerund and noun, respectively) and have very distinct mean-ings and usages. Benoliel (1987) sees the need to illuminatethe difference between knowing and knowledge:
Knowledge consists of concepts, theories, and ideas aboutan identified area of information, often presented in orga-nized form in textbooks and monographs. Knowing can beviewed as an individual’s perceptual awareness of the com-plexities of a particular situation and draws upon innerknowledge resources that have been garnered throughexperience in living. (p. 151)
Jacobs-Kramer and Chinn (1988) define personal knowl-edge as expressing knowledge of self in experiencing,encoun-tering, and focusing—all ongoing, subjective processes. Moch(1990) describes personal knowing as entailing a “shift inconnectedness/transcendence” (p. 159) and defines compo-nents of personal knowing as experiential, interpersonal, andintuitive—all continuing as inner experiences.
Pattern and Way. As with the interchange of the wordsknowing and knowledge, the different words pattern and wayundergo similar transfer and application. What is the differ-ence between a pattern of knowing and a way of knowing?Each of Carper’s patterns is customarily and interchangeablyreferred to using both descriptive words. However, the notionof pattern is specific and is a concept with dimensional impli-cations. A way is more specific and relatively concrete, withlimited horizons of use.
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Chapter 1: Synoptic Knowing for a Synoptic Practice of Nursing 7These other ways of knowing do not necessarily consti-
tute new patterns of knowing commensurate with the com-plexity and scope of patterns introduced by Carper. Thisposes a problem in that all identified patterns are of value,but when ways that are context dependent or of a narrowerfocus are aligned among the four fundamental patterns, thedynamic relationship and unity among the original patternslose balance and coherence. This alignment and differencein magnitude again point to and affirm the problem outlinedearlier: There is a certain lack of capacity among Carper’sfour fundamental patterns of knowing.
Therefore, the scope of these later ways is better under-stood as a sub-pattern, category, or aspect that illustratesincreasing complexity or specialization among larger pat-terns of knowing. From this narrower perspective, knowingas a way rather than a pattern becomes an appropriate fit.
The original problem remains, however, regardless ofany taxonomy that one might propose at this point in thediscussion: Nurse scholars are finding the fundamental pat-terns inadequate and are seeking meanings that answer theirpractice in ways of knowing beyond the perceived scope ofthe patterns.
Looking Beyond the Scope. In considering Carper’s pat-terns of knowing, each appeals to cognition or psychologi-cal processes. Each also appears to be “thinned” in meaningor without a certain capacity when suited to the individualprocesses of knowing. The interchange between the wordsknowing and knowledge contributes to this thinning: Meaningfrom knowledge must be inferred and is somewhat removedfrom immediacy. Meaning in knowing is experienced in themoment. This is evidenced by the narrower conceptual levelof the more recent idea of embodied knowing (Rischel, Lar-son, & Jackson, 2008) that resonates with the experience ofso many nurses.
Carper states that understanding the four fundamen-tal patterns “does not extend the range of knowledge, butrather involves critical attention to the question of what itmeans to know and what kinds of knowledge are held tobe of most value in the discipline of nursing” (p. 13). Thisrather abstruse statement does not help our understandingin light of the frequent crossover in understanding of terms.The subtle distinction between what it means to know, as
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8 Part I: Philosophical, Theoretical, and Historical Perspectives of Knowing
opposed to what knowing means, is taken up by Silva, Sor-rell, and Sorrell (1995) in their description of an ontologi-cal philosophical shift in nursing. Silva et al. identify threemajor limitations of Carper’s (1978) work.
They assert that first, the title of the article “Fundamen-tal Patterns of Knowing in Nursing” suggests a process, butyet the patterns are shown as end products. How one comesto know the knowledge in these patterns is not adequatelyaddressed. Second, they argue that each pattern is presentedas a discrete entity, contributing to understanding, use, andresearch of the patterns discretely. That distinction resultsin the richness of Carper’s work being lost or passed overin favor of a more linear, formulaic application. Third, andmost important in this discussion, Silva, Sorrell, and Sorrellpoint out that two-dimensional aspects of knowing emergedinstead of multidimensional aspects.
As a result of the dimensional paucity they perceived,Silva et al. (1995) coined the terms the in-between and thebeyond (p. 3) to account for the ontological aspects they sawemerging from within Carper’s epistemological focus. Theyobserved the change in thinking spurred by cyberspace andvirtual reality, and the trend of nurses toward raising onto-logical questions concerning the nature and meaning ofreality.Thus, they found that when Carper’s four patterns areused to address all types of epistemological and ontologicalknowing within nursing theory and research, the researchquestions become mixed and a certain dissonance ensues.Silva et al. (1995) state succinctly and poignantly 13 yearslater, “The issue is that often nurses do not recognize thisdissonance and, even when appropriate, do not move beyondepistemological questions to ontological questions thataddress issues of reality, meaning, and being” (p. 4). Includedamong contemporary critics, however, are non-nurses withperspectives from other disciplines, who propose to furtherthin or limit the valuing and experience of nurses’ knowingby relegating their experiences to the “supervisory and cor-rective function” (Paley, Cheyne, Dalgleish, Duncan, & Niven,2007, p. 692) of rule-based, analytical forms of cognition incognitive science.This interpolation of knowledge from otherdisciplines under the guise of “science” and “evidence” lendsfurther impetus to the necessity of clarifying what is con-sidered knowledge in the discipline of nursing, including itsprovenance and philosophical groundings within the rela-
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Chapter 1: Synoptic Knowing for a Synoptic Practice of Nursing 9tionship of the nurse and the one nursed. At this juncture,the separation in differences of meaning between knowledgeand knowing is clear.
Turning to the Source. In turning to Phenix’s (1964) work,Realms of Meaning, we are able to understand the founda-tional background to Carper’s 1978 work, “Fundamental Pat-terns of Knowing in Nursing.”The purpose in turning back toPhenix is to weigh ideas and search for answers that suggesthow fundamental patterns of knowing might be drawn for-ward and re-visioned for a contemporary, meaningful prac-tice of nursing. Carper’s profound contribution has helpedgenerations of nurses to distinguish their own practice asuniquely nursing, and to move away from non-nursing per-spectives (Silva et al., 1995) and we thus honor her work.
In the introduction to his work, Phenix (1964) states,“General education is the process of engendering essentialmeanings” (p. 5). This is the prelude to his idea that mean-ings are found in realms and sub-realms of distinctive kindsof knowledge within the various disciplines. Six realms ofmeanings provide foundations for “all the meanings thatenter the human experience” (p. 8). Each realm of meaningand its sub-realms has typical methods, leading ideas, andcharacteristic structures. In studying several disciplines heldto be the most important at the time, Phenix examined thegeneral logical character of the field, the distinctive sub-ject matter of the discipline, the representative ideas, andthe methods of inquiry. He found that various disciplinesor fields of knowledge exhibit distinctive structures or pat-terns of meanings. Today these differences are apparent inthe challenges of understanding often felt in interdisciplin-ary communications. The differences in focus, language, andmeanings in disciplinary knowledge often arise from vastlydifferent worldviews and types of endeavors.
These expressive realms of knowledge with their meaningsare briefly described, with the realms of meaning from whichCarper derived her patterns of knowing. Perhaps Carper’sgreatest and most frequently overlooked contribution to nurs-ing is her understanding that whereas Phenix found distinctiverealms of meaning and knowledge structures among clustersof similar disciplines, nursing uniquely engages in all realmssimultaneously. The notion of matching one distinctive realmof meaning to one discipline correspondence fell far short
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10 Part I: Philosophical, Theoretical, and Historical Perspectives of Knowing
in regard to nursing’s complex practice. The following briefdescriptions of Phenix’s realms of meaning stem from founda-tional types of disciplinary knowledge.
Synnoetics or personal knowledge. Phenix states that synnoet-ics, or subjective knowledge, relates to the kind of personalknowledge such as that found in Martin Buber’s close I-Thourelationship and reflects intersubjective understanding. Syn-noetics implies relational direct awareness and refers to mean-ings in which a person has direct insight into other personsexisting in relation.This kind of knowledge is concrete, direct,and existential, and it may apply to persons or objects. Mostimportantly for our consideration, personal knowledge is notdeveloped through formal instruction, even though it refers tohuman association, beginning with the family and extendingout to community, occupation, other cultures, and global asso-ciations. Phenix provides examples of four disciplines in thisrealm: religion, philosophy, psychology, and literature.
Empirics. Empirics (objective knowledge) includes the sci-ences of the physical world human beings, and other livingthings. Knowledge gained is based on observation and exper-imentation. Meanings are expressed as probable empiricaltruths using rules of evidence and verification. Disciplineswhose knowledge structure is primarily empirical includephysical sciences (matter), life sciences (life), psychology(mind), and social sciences (society).
Ethics. Ethics (objective knowledge) is the realm “thatincludes moral meanings that express obligation rather thanfact, perceptual form, or awareness of relation” (p. 7). Ethicshas to do with personal conduct based on free, responsibledecision.
Esthetics. In this realm (objective), meanings take the formof contemplative perception of significant, particular things,such as are found in the various arts. These are expressionsof subjective ideation or the creative mind, such as in music,visual arts, arts of movement, and literature.
The “Missing” Realms. Two other realms of meaning wereproposed by Phenix: symbolic and synoptic. These realmsare significant in that they are not addressed or included
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Chapter 1: Synoptic Knowing for a Synoptic Practice of Nursing 11by Carper and their properties were not reconceptualizedas fundamental patterns of knowing. In the discussion fol-lowing, however, they shall be seen to be of significant andenduring value to nursing.
The Symbolic Realm and Pattern of Knowing. Phenix (1964)states that symbolic systems constitute the most funda-mental of all realms because they must be used to expressmeanings of other realms. Symbolic knowing encompassesexperience and history and relates to values, ideals, andpurposes of existence. This realm of meaning is found inknowledge systems of ordinary language, nondiscursive,symbolic forms such as mathematics, rituals, gestures, andtacit understandings. Phenix holds that these “constitute themost fundamental of all of the realms of meaning and arefoundational to expression of meanings in each of the otherrealms” (p. 6). This understanding is significant because italso encompasses and shares the inarticulate; the unex-pressed or ineffable; the involuntary response; and abstrac-tion, such as the idea of a round square. It also allows valuesto surface.
When the meaning extrapolated from this realm is trans-ferred to the idea of knowing in a distinguishable pattern, theidea of symbolic knowing in nursing also becomes a funda-mental pattern identified among Carper’s original fundamen-tal patterns. We can see that ideas are readily transferred topractice. For example, the image of a nurse’s uniform invokestrust; a national flag calls forth meanings associated withbirth and patriotism. Language is itself a symbol and is syn-onymous with culture. This is a pattern that is fundamentalin its characteristics; however, it is here that the uniquenessand conceptual value of symbolic knowing changes how wemight view the relationships among patterns of knowing innursing.The symbolic realm, as Phenix noted, is foundationaland gives rise to or informs all other realms.
From this perspective, although all patterns are ofinherently “equal” value, a glimmer of a process is seen inthis relationship. Symbolic knowing may be understood asundifferentiated potential with the capacity for giving rise—from itself—to other patterns of knowing that richly vary incombination, dimension, and form, according to the mean-ings called forth from the unique and complex disciplinaryknowledge found in nursing practice.
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12 Part I: Philosophical, Theoretical, and Historical Perspectives of Knowing
It is this unique capacity on which we first focus ourattention and offer explanation for the variety and scopeof patterns of knowing extant in the nursing literature. Inunderstanding the tacit nature of symbolic knowing, itbecomes easy to understand, that this pattern of knowingis present always and answers to the meaning from nursingpractice.The glimmer of a process can be seen further in theidea that symbolic knowing is active in the idea of call andresponse within the nursing situation. Other patterns aresimultaneously being perceived tacitly and explicitly withinthe richness of nuanced practice. This capacity for express-ing differentiation, then, is a distinctive and significant func-tion of symbolic knowing in its role as a fundamental pattern,with the relationship between knowing and knowledge madeclear. We now turn our attention to the realm that Phenixcalls synoptic, which presents a paradox for consideration.
The Synoptic Realm and Pattern of Knowing. Phenix describesthe synoptic realm as one in which meanings are “compre-hensively integrative” (p. 7), and which includes history,religion, and philosophy. These disciplines combine empiri-cal, esthetic, and synnoetic meanings into coherent wholes(Ibid), and their knowledge is described by Phenix as objec-tive. Phenix states that synthesis of coordination with otherrealms through reflective interpretation of all other kindsof meaning and their relationships occurs in the synopticrealm. Of all the realms of meaning that Phenix illuminates,the synoptic realm is perhaps the most intriguing becauseit resonates with possibilities for the practice of nursing.Although Carper recognized that all patterns were inherentin nursing in the form of patterns of knowing, as previouslynoted, she did not include the idea of synoptic knowing itselfas a pattern in which all other patterns were brought togeth-er and integrated as a whole. The necessary transference ofthe concept of the synoptic realm to patterns of knowing innursing as synoptic or integrative knowing is as significantas the inclusion of symbolic knowing previously considered.
Synoptic knowing is the pattern that is at home withinthe nursing situation. Wholeness, caring, oneness, valuing,the “in between” and “the beyond” of Silva et al. (1995), tran-scendence, empathy, growth, intuition, and all such knowingthat is perceived and informed are embraced and includedwithin the nature of integration in this pattern. This is the
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Chapter 1: Synoptic Knowing for a Synoptic Practice of Nursing 13role of synoptic or integrative knowing: to fuse or synopsizein a unitary whole. The idea of ultimate meanings and whatPhenix terms “boundary concepts” (p. 7), such as the Whole,the Comprehensive, and the Transcendent where there areno boundaries, are included in synoptic knowing.
Creative characteristics of fundamental patterns of know-ing are expressed through synoptic knowing in the nursingsituation. Aesthetic knowing is inherently creative, and it isthis aspect that is seen in the perception and understandingof new knowledge brought forth in the nursing situation; thatis, nursing knowledge that might not yet be articulated. Thisis growth, an example of which may be understood as grow-ing in caring, and includes both nurse and the one nursed. Innursing, synoptic knowing unites all knowledge and expe-rience in the moment and creatively transforms them. Thiscritical pattern of knowing enables an individual, or a disci-pline in the collective sense, to grow and transform with theintegration of new knowledge and understandings.
The Unitary Nature of Symbolic and Synoptic Knowing What has not been addressed at this juncture is the paradoxalluded to in our discussion of synoptic knowing.We addressthis in a question. If symbolic knowing is the pattern fromwhich all others arise, then it must include synoptic know-ing; if synoptic knowing integrates all other patterns, then itmust include symbolic knowing. Which is it? The answer issimilarly puzzling: Neither and both.
Phenix provides the idea of a spectrum, at one end ofwhich are the symbolic fields of knowledge, from which allmeanings are expressed. At the other end of the spectrumare the synoptic fields, which gather up the entire range ofmeanings. In between these two realms are the four distinctbut interdependent realms of empirics, esthetics, and syn-noetics, which are “modes of significant human relatednessto the world and to existence” (p. 8). The symbolic and syn-optic realms “serve as binding elements running throughoutthe various realms and welding them into a single meaningfulpattern” (p. 9).
Patterns of symbolic knowing and synoptic knowing innursing, therefore, are merely two different expressions ofthe same knowing, rather like a double helix, between which
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14 Part I: Philosophical, Theoretical, and Historical Perspectives of Knowing
patterns of knowing such as personal, empiric, aesthetic, eth-ical, sociopolitical, and unknowing come into view and revealtheir unique characteristics. The fusion of all the patterns ofknowing into a single pattern, with meaning grounded in thedisciplinary knowledge of nursing, is the pattern which wewill now call synoptic or integrative knowing in nursing prac-tice.The nursing literature reveals a growing number of inte-grative theories of nursing practice. The knowing addressedwithin these theories should also be reflective, and shouldreflect the whole, as does synoptic knowing.
At the beginning of this paper, we raised the idea of a per-ceived “thinness” of the four fundamental patterns of know-ing. In Phenix’s fundamental realms as discussed, meaning isdrawn from the fields of knowledge that the realms typify andrepresent.When transferred as patterns of knowing in nursing,meaning is drawn from disciplinary nursing knowledge andinfused into fundamental patterns of knowing.This gives know-ing the life and fullness of meaning distinctive to nursing.
All patterns together are fluid and unbounded, andalthough they express different natures at different times,they are characteristic of the whole person within the nurs-ing situation, yet remain connected with the universe. It ishere that we see a new process of knowing and being thatis integral to living in an unbounded universe—one that isincreasingly supported by a bolder science and that turnsconventional, Newtonian scientific thought on its head. If thefocus of concern of the discipline of nursing is nursing in thehuman health experience, and if the essence of nursing iscaring, the nurse grounds practice in an explicit conception ofnursing grounded in caring (Boykin, Parker, & Schoenhofer,1994; Boykin & Schoenhofer, 1993). This is where meaningresides.This is where synoptic or integrative knowing occurs.This is where there are no boundaries.
Phoenix Arising. This chapter began with the story of themysterious phoenix as a metaphor for courage, change, andcontinuance. In telling the story of the epistemological rootsof our knowing in nursing, we built our nest of wood andsettled deep. The consuming of the old in the fire of insightand understanding has raised us up in a new form, morebeautiful, and able to live on in wisdom and surety.
Both Barbara Carper, nursing scholar, and Philip Phenix,education scholar, whose opuses we have been considering,
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Chapter 1: Synoptic Knowing for a Synoptic Practice of Nursing 15have provided the foundations for the re-visioning of thisphoenix, or in true understanding of what the name means,metamorphosis or change. We are indebted to them.
Summary
We began this examination of fundamental patterns of know-ing in nursing with the premise that something was missingfrom the patterns and was not explained or accounted for.Weturned back the pages of our epistemology to seek to under-stand the realms of meaning whose sources were discov-ered in Phenix and expressed for nursing in Carper’s work.Two realms of meaning—symbolic and synoptic—were notincluded in the envisioning of the four original fundamentalpatterns of knowing in nursing, but were found to answeruniquely to a contemporary process of knowing in nursingpractice. Both newly termed as patterns of knowing in nurs-ing, these were found to be two aspects of the same knowingthat were differentiated by their functions. This knowing innursing is called synoptic or integrative knowing.
Reflections
As a young discipline of knowledge with unique complexi-ties in practice, we are only at the beginning of our journey.As human beings, our knowing and intentionality are morecomplex and wonderful than we have ever dreamed, yet wehave hardly begun. Our unique nursing caring is the invita-tion for exquisite healing of those who are wounded, and themyriad ways this is being lived in practice have only begunto be chronicled. In a contemporary process of nursing, ourunbounded knowing and being enables us to simultaneouslybe at the bedside and in the stars. Our search for knowledgeis so that we can tell the story of our own humanity andthe desire for goodness and kindness that thread their waythrough our lives. This we do through nursing.
Sullivan in Phenix (1964) states magnificently, “It is onlywhen the world expands as a tissue of persons and inter-personal relations which are meaningful that knowledgebecomes truly significant” (p. 200).
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16 Part I: Philosophical, Theoretical, and Historical Perspectives of Knowing
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