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23

Source: Carper, B. A. (1978). Fundamental patterns of knowing in nursing. ANS, 1 (1): 13–24.
Reprinted with permission from and copyright © 1978 Aspen Publishers, Inc

CHAPTER 3

Fundamental Patterns of
Knowing in

Barbara A. Carper, RN, EdD

It is the general conception of any field of
inquiry that ultimately determines the kind
of knowledge the field aims to develop as well
as the manner in which that knowledge is to
be organized, tested, and applied. The body
of knowledge that serves as the rationale for
nursing practice has patterns, forms, and
structure that serve as horizons of expecta-
tions and exemplify characteristic ways of
thinking about phenomena. Understanding
these patterns is essential for the teaching and
learning of nursing. Such an understanding
does not extend the range of knowledge, but
rather involves critical attention to the ques-
tion of what it means to know and what kinds
of knowledge are held to be of most value in
the discipline of nursing.

Identifying Patterns
of Knowing

Four fundamental patterns of knowing
have been identified from an analysis of the
conceptual and syntactical structure of nurs-
ing knowledge.

1
The four patterns are distin-

guished according to logical type of meaning
and designated as (1) empirics, the science
of nursing; (2) esthetics, the art of nursing;
(3) the component of a personal knowledge
in nursing; and (4) ethics, the component of
moral knowledge in nursing.

Empirics: The Science of

The term nursing science was rarely used
in the literature until the late 1950s. However,

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24 Chapter 3: Fundamental Patterns of Knowing in

since that time, there has been an increas-
ing emphasis, one might even say a sense
of urgency, regarding the development of
a body of empirical knowledge specific to
nursing. There seems to be general agree-
ment that there is a critical need for knowl-
edge about the empirical world, knowledge
that is systematically organized into general
laws and theories for the purpose of describ-
ing, explaining, and predicting phenomena
of special concern to the discipline of nurs-
ing. Most theory development and research
efforts are primarily engaged in seeking and
generating explanations that are systematic
and controllable by factual evidence and that
can be used in the organization and classifica-
tion of knowledge.

The pattern of knowing that is generally
designated as “nursing science” does not
presently exhibit the same degree of highly
integrated abstract and systematic explana-
tions characteristic of the more mature sci-
ences, although nursing literature reflects this
as an ideal form. Clearly, there are a number
of coexisting, and in a few instances compet-
ing, conceptual structures—none of which
has achieved the status of what Kuhn calls a
scientific paradigm. That is, no single con-
ceptual structure is as yet generally accepted
as an example of actual scientific practice
“which include[s] law, theory, application,
and instrumentation together . . . [and]
. . . provide[s] models from which spring
particular coherent traditions of scientific
research.”

2(p10)
It could be argued that some

of these conceptual structures seem to have
greater potential than others for providing
explanations that systematically account for

observed phenomena and may ultimately
permit more accurate prediction and con-
trol of them. However, this is a matter to be
determined by research designed to test the
validity of such explanatory concepts in the
context of relevant empirical reality.

New Perspectives What seems to be of
paramount importance, at least at this stage
in the development of nursing science, is that
these preparadigm conceptual structures and
theoretical models present new perspectives
for considering the familiar phenomena of
health and illness in relation to the human
life process; as such, they can and should be
legitimately counted as discoveries in the
discipline. The representation of health as
more than the absence of disease is a crucial
change; it permits health to be thought of as
a dynamic state or process that changes over
a given period of time and varies according
to circumstances rather than a static either/or
entity. The conceptual change in turn makes
it possible to raise questions that previously
would have been literally unintelligible.

The discovery that one can usefully con-
ceptualize health as something that normally
ranges along a continuum has led to attempts
to observe, describe, and classify variations in
health, or levels of wellness, as expressions of
a human being’s relationship to the internal
and external environments. Related research
has sought to identify behavioral responses,
both physiological and psychological, that
may serve as cues by which one can infer the
range of normal variations of health. It has
also attempted to identify and categorize
significant etiological factors that serve to
promote or inhibit changes in health status.

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Identifying Patterns of Knowing 25

conditions for the normal development of
an individual.

Thus, the first fundamental pattern of
knowing in nursing is empirical, factual,
descriptive, and ultimately aimed at devel-
oping abstract and theoretical explanations.
It is exemplary, discursively formulated, and
publicly verifiable.

Esthetics: The Art of

Few, if indeed any, familiar with the pro-
fessional literature would deny that primary
emphasis is placed on the development of
the science of nursing. One is almost led to
believe that the only valid and reliable knowl-
edge is that which is empirical, factual, objec-
tively descriptive, and generalizable. There
seems to be a self-conscious reluctance to
extend the term knowledge to include those
aspects of knowing in nursing that are not
the result of empirical investigation. There
is, nonetheless, what might be described as a
tacit admission that nursing is, at least in part,
an art. Not much effort is made to elaborate
or to make explicit this esthetic pattern of
knowing in nursing—other than to associate
vaguely the “art” with the general category of
manual and/or technical skills involved in
nursing practice.

Perhaps this reluctance to acknowledge the
esthetic component as a fundamental pattern
of knowing in nursing originates in the vigor-
ous efforts made in the not-so-distant past
to exorcise the image of the apprentice-type
educational system. Within the apprentice
system, the art of nursing was closely associ-
ated with an imitative learning style and the
acquisition of knowledge by accumulation

Current Stages The science of nursing at
present exhibits aspects of both the “natu-
ral history stage of inquiry” and the “stage
of deductively formulated theory.” The task
of the natural history stage is primarily the
description and classification of phenomena
that are, generally speaking, ascertainable by
direct observation and inspection,

3
but cur-

rent nursing literature clearly reflects a shift
from this descriptive and classification form
to increasingly theoretical analysis, which is
directed toward seeking, or inventing, expla-
nations to account for observed and classified
empirical facts. This shift is reflected in the
change from a largely observational vocabu-
lary to a new, more theoretical vocabulary
whose terms have a distinct meaning and
definition only in the context of the corre-
sponding explanatory theory.

Explanations in the several open-system
conceptual models tend to take the form
commonly labeled functional or teleological.

4

For example, the system models explain a
person’s level of wellness at any particular
point in time as a function of current and
accumulated effects of interactions with his
or her internal and external environments.
The concept of adaptation is central to this
type of explanation. Adaptation is seen
as crucial in the process of responding to
environmental demands (usually classi-
fied as stressors) and enables an individual
to maintain or reestablish the steady state,
which is designated as the goal of the system.
The developmental models often exhibit a
more genetic type of explanation in that
certain events, the developmental tasks, are
believed to be causally relevant or necessary

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26 Chapter 3: Fundamental Patterns of Knowing in

exemplary and leads us to acknowledge that
“knowledge—genuine knowledge, under-
standing—is considerably wider than our
discourse.”

7(p23)

For Wiedenbach, the art of nursing is
made visible through the action taken to pro-
vide whatever the patient requires to restore
or extend his [sic] ability to cope with the
demands of his [sic] situation,

8
but the action

taken, to have an esthetic quality, requires
the active transformation of the immedi-
ate object—the patient’s behavior—into a
direct, nonmediated perception of what is
significant in it—that is, what need is actu-
ally being expressed by the behavior. This
perception of the need expressed is not only
responsible for the action taken by the nurse
but reflected in it.

The esthetic process described by
Wiedenbach resembles what Dewey refers
to as the difference between recognition and
perception.

9
According to Dewey, recog-

nition serves the purpose of identification
and is satisfied when a name tag or label is
attached according to some stereotype or
previously formed scheme of classification.
Perception, however, goes beyond recogni-
tion in that it includes an active gathering
together of details and scattered particulars
into an experienced whole for the purpose of
seeing what is there. It is perception rather
than mere recognition that results in a unity
of ends and means that gives the action taken
an esthetic quality.

Orem speaks of the art of nursing as
being “expressed by the individual nurse
through her creativity and style in design-
ing and providing nursing that is effective

of unrationalized experiences. Another likely
source of reluctance is that the definition of
the term art has been excessively and inap-
propriately restricted.

Weitz suggests that art is too complex and
variable to be reduced to a single definition.

5

To conceive the task of esthetic theory as defi-
nition, he says, is logically doomed to failure
in that what is called art has no common
properties—only recognizable similarities.
This fluid and open approach to the under-
standing and application of the concept of art
and esthetic meaning makes possible a wider
consideration of conditions, situations, and
experiences in nursing that may properly be
called esthetic, including the creative pro-
cess of discovery in the empirical pattern of
knowing.

Esthetics Versus Scientific Meaning De-
spite this open texture of the concept of art,
esthetic meanings can be distinguished from
those in science in several important aspects.
The recognition “that art is expressive rather
than merely formal or descriptive,” accord-
ing to Rader, “is about as well established as
any fact in the whole field of esthetics.”

6(p xvi)

An esthetic experience involves the creation
and/or appreciation of a singular, particular,
subjective expression of imagined possibili-
ties or equivalent realities that “resists projec-
tion into the discursive form of language.”

7

Knowledge gained by empirical description
is discursively formulated and publicly veri-
fiable. The knowledge gained by subjective
acquaintance, the direct feeling of experience,
defines discursive formulation. Although an
esthetic expression required abstraction,
it remains specific and unique rather than

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Identifying Patterns of Knowing 27

same time, increased awareness of the vari-
ety of subjective experiences will heighten
the complexity and difficulty of the decision
making involved.

The design of nursing care must be accom-
panied by what Langer refers to as sense of
form, the sense of “structure, articulation, a
whole resulting from the relation of mutually
dependent factors, or more precisely, the way
the whole is put together.”

7(p16)
The design, if

it is to be esthetic, must be controlled by the
perception of the balance, rhythm, propor-
tion, and unity of what is done in relation to
the dynamic integration and articulation of
the whole. “The doing may be energetic, and
the undergoing may be acute and intense,”
Dewey says, but “unless they are related to
each other to form a whole,” what is done
becomes merely a matter of mechanical rou-
tine or of caprice.

9

The esthetic pattern of knowing in nursing
involves the perception of abstracted particu-
lars as distinguished from the recognition of
abstracted universals. It is the knowing of a
unique particular rather than an exemplary
class.

The Component of Personal
Knowledge

Personal knowledge as a fundamental
pattern of knowing in nursing is the most
problematic, the most difficult to master and
to teach. At the same time, it is perhaps the
pattern most essential to understanding the
meaning of health in terms of individual well-
being. considered as an interpersonal
process involves interactions, relationships,
and transactions between the nurse and the

and satisfying.”
10(p155)

The art of nursing
is creative in that it requires development
of the ability to “envision valid modes of
helping in relation to ‘results’ which are
appropriate.”

10(p69)
This again invokes

Dewey’s sense of a perceived unity between
an action taken and its result—a perception
of the means of the end as an organic whole.

9

The experience of helping must be perceived
and designed as an integral component of its
desired result rather than conceived sepa-
rately as an independent action imposed on
an independent subject. Perhaps this is what
is meant by the concept of nursing the whole
patient or total patient care. If so, what are the
qualities that enable the creation of a design
for nursing care that eliminate or would min-
imize the fragmentation of means and ends?

Esthetic Pattern of Knowing

Empathy—that is, the capacity for par-
ticipating in or vicariously experiencing
another’s feelings—is an important mode in
the esthetic pattern of knowing. One gains
knowledge of another person’s singular,
particular, felt experience through empathic
acquaintance.

11,12
Empathy is controlled or

moderated by psychic distance or detach-
ment in order to apprehend and abstract
what we are attending to and in this sense
is objective. The more skilled the nurse
becomes in perceiving and empathizing
with the lives of others, the more knowledge
or understanding will be gained of alternate
modes of perceiving reality. The nurse will
thereby have available a larger repertoire of
choices in designing and providing nursing
care that is effective and satisfying. At the

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28 Chapter 3: Fundamental Patterns of Knowing in

Maslow refers to this sacrifice of form as
embodying a more efficient perception of
reality in that reality is not generalized nor
predetermined by a complex of concepts,
expectations, beliefs, and stereotypes.

15
This

results in a greater willingness to accept ambi-
guity, vagueness, and discrepancy of oneself
and others. The risk of commitment involved
in personal knowledge is what Polanyi calls
the “passionate participation in the act of
knowing.”

16(p17)

The nurse in the therapeutic use of self
rejects approaching the patient–client as
an object and strives instead to actualize
an authentic personal relationship between
two persons. The individual is considered
as an integrated, open system incorporating
movement toward growth and fulfillment
of human potential. An authentic personal
relation requires the acceptance of others in
their freedom to create themselves and the
recognition that each person is not a fixed
entity, but constantly engaged in the process
of becoming. How then should the nurse rec-
oncile this with the social and/or professional
responsibility to control and manipulate the
environmental variables and even the behav-
ior of the person who is a patient in order to
maintain or restore a steady state? If a human
being is assumed to be free to choose and
chooses behavior outside of accepted norms,
how will this affect the action taken in the
therapeutic use of self by the nurse? What
choices must the nurse make in order to
know another self in an authentic relation
apart from the category of patient, even when
categorizing for the purpose of treatment is
essential to the process of nursing?

patient-client. Mitchell points out that “there
is growing evidence that the quality of inter-
personal contacts has an influence on a per-
son’s becoming ill, coping with illness and
becoming well.”

13(p4950)
Certainly the phrase

“therapeutic use of self,” which has become
increasingly prominent in the literature,
implies that the way in which nurses view
their own selves and the client is of primary
concern in any therapeutic relationship.

Personal knowledge is concerned with the
knowing, encountering, and actualizing of
the concrete, individual self. One does not
know about the self; one strives simply to
know the self. This knowing is a standing in
relation to another human being and con-
fronting that human being as a person. This
“I–Thou” encounter is unmediated by con-
ceptual categories or particulars abstracted
from complex organic wholes.

14
The relation

is one of reciprocity, a state of being that can-
not be described or even experienced—it can
only be actualized. Such personal knowing
extends not only to other selves but also to
relations with one’s own self.

It requires what Buber refers to as the sac-
rifice of form, that is, categories or classifica-
tions, for a knowing of infinite possibilities,
as well as the risk of total commitment.

Even as a melody is not composed
of tones, nor a verse of words, nor a
statue of lines-one must pull and tear
to turn a unity into a multiplicity—
so it is with the human being to
whom I say You. . . . I have to do this
again and again; but immediately he
is no longer You.

14(p59)

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Identifying Patterns of Knowing 29

within the complex context of modern health
care. These choices raise fundamental ques-
tions about morally right and wrong action
in connection with the care and treatment of
illness and the promotion of health. Moral
dilemmas arise in situations of ambiguity and
uncertainty, when the consequences of one’s
actions are difficult to predict and traditional
principles and ethical codes offer no help or
seem to result in contradiction. The moral
code that guides the ethical conduct of nurses
is based on the primary principle of obligation
embodied in the concepts of service to people
and respect for human life. The discipline of
nursing is held to be a valuable and essential
social service responsible for conserving life,
alleviating suffering, and promoting health,
but appeal to the ethical “rule book” fails to
provide answers in terms of difficult individ-
ual moral choices, which must be made in the
teaching and practice of nursing.

The fundamental pattern of knowing iden-
tified here as the ethical component of nursing
is focused on matters of obligation or what
ought to be done. Knowledge of morality goes
beyond simply knowing the norms or ethical
codes of the discipline. It includes all volun-
tary actions that are deliberate and subject to
the judgment of right and wrong—including
judgments of moral value in relation to motives,
intentions, and traits of character. is
deliberate action, or a series of actions, planned
and implemented to accomplish defined goals.
Both goals and actions involve choices made,
in part, on the basis of normative judgments,
both particular and general. On occasion, the
principles and norms by which such choices
are made may be in conflict.

Assumptions regarding human nature,
McKay observes, “Range from the …

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