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Ways of knowing

Carper’s ways of knowing are a way to
structure the thought process of a nurse. A nurse can use this framework to
reflect on their own process and their own knowledge. Most importantly it can
be used to improve knowledge. This paper will use Carper’s ways of knowing to
reflect on personal experiences, in order to expand the knowledge of the nurse
writing.

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Empirical
way of knowing

                Carper
describes the empirical way of knowing as empirical evidence “knowledge
that is systematically organized into general laws and theories for the purpose
of describing, explaining, and predicting phenomena of special concern to the
discipline of nursing”(as cited in Johns, 1995, p. 227). The following
patient’s distress was put at easy by using empirical evidence from
observations noticed during an assessment of a patient’s complaint. Upon
arrival to the floor I received a report that my patient came in originally
with an altered mental status, urinary tract infection, and respiratory
distress. The patient had been in the ICU for days and their kidneys had shut
down with an output of twenty milliliters a day for the past two days. The
patient also had a urinary catheter in place. The physicians had decided that
the patient’s body was shutting down and if invasive procedures were not
performed the patient would die. The family had decided they did not want to
put their loved one through anything more. The patient was sent to my floor
that day to wait for arrangements for hospice care.

            During assessment the patient
complained of stomach pain, bladder distention was noted upon palpation, and
catheter inspection revealed urine leaking around the catheter. Bladder scan
showed 510 milliliters. The physician was called to obtain an order to flush
the catheter, which was granted with the given empirical. Sixty milliliters of sterile
water were flushed through the catheter and then sixty milliliters were removed
directly following the flush. Once finished it was left alone to drain. The
final count of urine out of the catheter after the intervention was 2000
milliliters. The patients pain was relieved by using information found
physically on the patient to determine where the pain was from. According to
Marklew (2004) “Approximately half of all patients with a urinary catheter
are prone to blockage, secondary toe encrustation” (p.22). It has also
been found that it is most frequent in patient with urinary tract infections
(Marklew, 2004, p. 23).

Personal
Way of Knowing

            The personal way of knowing is about
self and self-understanding. To care for one therapeutically and have a
therapeutic relationship with a patient it is important to know and understand
yourself, reflect on yourself and learn from your reflection. According to
Leenerts (2003) “Personal knowledge is conceptualized as awareness of self
in therapeutic relationship. By conceptualizing personal knowledge as
fundamental, it becomes a precondition for establishing therapeutic relationships.”
Therefore, knowing yourself will help guide you to the best intervention you
have to offer within your own abilities.

            I have deep sympathy for my
patients. I do care for them and what they are going through, but I am also
aware that when their emotions get deep because of what they are going through
I tend to freeze. I want to fix everyone and there are some people that cannot
be fixed and the fact that I cannot fix them bothers me, so I freeze, which
brings me to a patient I had with colon cancer. The patient was still quite
young and had undergone chemo, then a bowel resection. The bowel resection was
not healed correctly, therefore they had to go back in and resect some more. By
the time I was to take care of the patient they had an ileostomy, a Foley, and
had just learned of an infection developing. The patient was in a lot of pain
and was feeling hopeless. At one point they began to cry and pour their heart
out to me. I did freeze at first, the patient looked at me and asked,
“Don’t you have anything to say.” This is my weakness, but what I do
well with is honesty. It has been my experience that honesty can pull you
through anything. The patients statement unfroze me, I looked at the patient
and said, “I want to fix you, but I can’t, all I can do is; do my best to
make you as comfortable as possible, care for your wounds and help you slowly
heal. It kills me that this is my only option.” The patient then looked at
me and smiled. From that point I sat and listen to the patient. We worked
together to figure out what they needed most. We decided pain control and
education was most needed. Throughout the night I collected information for
them and different pain intervention options. At each stop to their room I made
sure I listened and had casual conversation. The patients spirit had lifted by
morning. In this experience knowing my strength helped me overcome my weakness
and built a strong relationship with the patient.

Aesthetic
Pattern of Knowing

The aesthetic pattern of knowing is the
opposite of the empirical way of knowing. According to Bender and Elias (2016)
the aesthetic way of knowing is a nurse’s “ability to deliberately gather
together several singular events and small details about what is happening and
merge them together to create a holistic picture of what is really actually
taking place.” Therefore, the nurse despite all evidence provided is able
to see through what lies in front of them to determine the root of the real
problem.

The aesthetic quality of a nurse is clearer
when caring for a patient that is unable to communicate for themselves. A patient
with a history of stroke had been admitted to the floor, had expressive
aphasia, hearing loss, anxiety incontinence of bowel and bladder, dementia and
weakness. This admission was for a three day stay. The patient had several
falls at home and the family felt they could no longer take care of them. Upon
report the patient had been found trying to get out of bed several times, all
fall precautions such as bed alarms, fall signs and watch had been implemented.
During this shift the patient appeared relatively calm at every interaction.
During one assessment the patient was found tossing themselves around in bed,
moaning, and pulling at their clothes. Support staff explained that this was
what had been going on during the stay that was talked about during report, and
it would be best to give the patient the Ativan prescribed. Looking closer at
the motion the patient was making with their hand it was noticed that they were
not just pulling at their clothes and trying to remove them, but they were
pulling on their brief specifically. A urinal was brought to the patient at the
time and placed appropriately, at that moment the patient calmed and urinated.
Following that moment when the patient began to get fidgety the patient was
given the means to eliminate and there were no longer moments of extreme
distress and attempts to jump out of bed.

It is important to remember when caring
for a patient that a patient with physical function loss and the inability to
communicate, in what is perceived the normal manner, does not mean a patient
has completely lost their thought processes. The patient above had lost their
ability to attend to their own elimination process causing incontinence, but
had not lost their ability to feel that it was not right to relieve themselves
in bed. The aesthetic of knowing in nursing is being able to feel out whether a
patient is having a mental problem or is just trying to communicate a need that
is unmet. There is not any hard evidence to show a nurse what is need in this
situation, the nurse must remember the patient’s humanity and find their way to
the root of the problem.

Ethical
Pattern of Knowing

Ethics is a complicated subject. As a
nurse it is important to give the best possible care to a patient and to do
what is best for the patient. Sometime the best medical option is not the
option for the patient and a nurse must always keep this in mind. Holtslander
(2008) describes this ethical pattern of knowing as “matters of obligation
and what ought to be done” (p.29). It is the responsibility of the nurse
to evaluate and reevaluate the effectiveness of care and do what needs to be
done (Holtslander, 2008, p.29). Nurses do this with every shift and often do
not realize they are fulfilling an ethical obligation to their patients.

Preparing a patient for surgery is part of
regular routine on the floor, and with every surgery a blood consent must be
signed, a nurse to explain that if complications arise that causes excessive
blood loss the surgical team must know that they can administer blood. Patient
frequently do not give much thought to this consent. The majority are ready to
except blood to save their life. Recently, going through the consent form
process with a patient I was faced with a rarity. The patient did not want
blood. The patient was ready to die if it was their time. As a nurse not
wanting to be resuscitated makes sense to me, especially in severely ill, but I
had never contemplated something as seemingly simple as a blood transfusion
being refused. The patient had no deep religious reasoning, they just did not
want to receive blood. What I wanted to do was say “Come on, it is just a
little blood, no beating on your chest, or zapping you with paddles, just a
little refill in case things get out of hand.” Obviously, this statement
was not possible. There was only one thing I could do. Remember my obligation
to this patient. It was not to talk them out of it, and change their mind. My
responsibility to the patient was to educate them on the administration of
blood products and inform them of what may happen in the event blood products
are not given when indicated before they checked the refusal box. The patient must
choose what they feel is right for them.  

Concluding
Thoughts

An important part of nursing is reflecting
on yourself as a nurse. Without self-reflection there can be no improvement in your
craft. The ways of knowing framework allows a nurse to not only look at what they
have done, but give them a way to see where it might come from within them. It allows
them to see their strengths and weaknesses.  

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