DE GRUYTER International Journal of Nursing Education Scholarship.

2018; 20170043

T. Diane Campbell1 / Kelly Penz1 / Marie Dietrich-Leurer1 / Karen Juckes1 / Kathy Rodger1

Ways of Knowing as a Framework for Developing

Reflective Practice among Nursing Students
1 Nursing, University of Saskatchewan, Regina, Saskatchewan, Canada, E-mail: diane.campbell@usask.ca

Abstract:
Abstract Background:Nursing students face the challenge of developing a comprehensive understanding of the
complex role of the registered nurse across various clinical settings. Frameworks such as the “ways of know-
ing”, help students conceptualize and critically reflect upon important processes in their professional learning.
However, the academic language used to describe frameworks can be challenging. Purpose: This manuscript
has two purposes. First, to briefly describe the historical climate influencing the development of nursing as a
discipline. Second, two clinical practicum scenarios in acute care and community-based care are explored with
the application of Carper’s four fundamental ways of knowing in nursing (empirical, aesthetic, self-knowledge,
ethical), and Chinn and Kramer’s fifth, emancipatory, knowing as foundational to developing reflexivity in
clinical practice. Conclusion: These practical descriptions and concrete examples can assist students in incor-
porating the five ways of knowing into their reflective practice and thereby more fully develop their construct
of nursing.
Keywords: undergraduate nursing education, ways of knowing, clinical practice, nursing students, reflective
practice
DOI: 10.1515/ijnes-2017-0043
Received: June 13, 2017; Revised: March 26, 2018; Accepted: April 3, 2018

Internationally, the profession of nursing can offer incoming students diverse and rewarding career oppor-
tunities. However, a particular challenge students face is developing a comprehensive understanding of the
complex role of the registered nurse across various clinical settings and domains of practice. At a baccalaureate
nursing education program at a large university in Western Canada, students enrolled in fourth year clinical
courses in both acute and community placements are required to use selected typologies; Carper’s “fundamen-
tal ways of knowing in nursing” (1978) and Chinn and Kramer’s (2008) “emancipatory knowing” to guide their
development of a reflective clinical practice. Although both typologies have been well defined in the literature
(Carnago & Mast, 2015; Wagner & Christensen, 2015; White, 1995; Zander, 2007), students have expressed the
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ongoing challenges of comprehending ‘how’ these ways of knowing can be applied within clinical situations,
and articulating the same in their clinical reflective journal assignments.
According to Boud (2010), reflection is needed in the profession of nursing where there is a particular em-
phasis on personal interaction between a professional and a client. Reflective practice is defined as the process
through which professionals are expected to mediate their learning and personal development (Hargreaves,
2009). Various benefits and outcomes of critical reflection are found in the literature and include: “better in-
formed practice; self-awareness and emotional support; more inclusive and emancipatory practice and im-
proved professionalism, collegiality and organizational learning” (Fook & Gardner, 2007, p. 143). Frameworks,
such as the “ways of knowing”, help students conceptualize and critically reflect upon important processes
in professional learning (Boud, 2010; Horsfall, Cleary & Hunt, 2011). Reflection offers a supportive model to
thinking about what we are doing and why and provides a strategy for improvement (Boud, 2010; Horsfall et
al.,2011).
The purposes of this paper are two-fold. First, to briefly describe the historical climate influencing the de-
velopment of nursing as a discipline, and the subsequent nature of knowledge in nursing practice. Second, two
clinical practicum scenarios in both acute care and community-based care will be explored with the applica-
tion of Carper’s (1978) four fundamental ways of knowing in nursing (i. e., empirical, aesthetic, self-knowledge,
ethical), and Chinn and Kramer (2008) fifth emancipatory knowing as foundational to developing reflexivity in
clinical practice. The description of the two clinical applications can aid students in understanding and using
this framework in their practice.

T. Diane Campbell is the corresponding author.

© 2018 Walter de Gruyter GmbH, Berlin/Boston.

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Brief history of nursing

In the mid nineteenth century, it was believed that every woman had the capacity to be a nurse by virtue of
the fact that the females in families were often called upon to care for the sick or infirm in their homes (Small,
1999). Nursing was initially performed by women of lower social classes who found themselves living in the
same dismal conditions as those for who they were attempting to care. The first nurse educators were physicians
whose primary motivation appeared to be to increase their client base in hospitals (Selanders, 1995). Florence
Nightingale struggled to separate nursing from medicine and to make nursing a separate profession by ensur-
ing nurses were educated and trained appropriately and not to only provide a source of cheap labour for hos-
pitals. Nightingale strongly believed that nurses had a distinct role separate from the physicians’. Nightingale
did not suggest that nurses were more or less important than physicians, but rather had a different capacity for
caring for the sick (Small, 1999). To this end, nursing would need its own knowledge base to guide its practice.
Nearly Hundred years later, in the 1950s, members of the nursing profession began to discuss the need
to develop, articulate, and test nursing theory (Alligood & Chong Choi, 1998). Theory development emerged
from nurse leaders who saw the limitations of theory from other disciplines to describe, predict, and explain
nursing outcomes (Alligood & Chong Choi, 1998). It was time for nurses to take their profession and make it
their own through development of their own knowledge base. In 1978, Carper produced an influential article
which provided descriptions of four patterns of knowing in nursing. Carper’s pattern description has been
considered by many to be the epistemology of nursing as it has served as a framework for nursing practice and
education (Hunter, 2008; McGovern, Lapum, Clune, & Schindel Martin, 2013; Zander, 2007).

Knowledge in nursing
Prior to examining ways of knowing in nursing, it is important to establish the philosophical basis of knowledge
in nursing as a whole. Nursing is a practice-based discipline that has a professional and societal mandate to
utilize a body of knowledge and skills aimed at providing quality patient care (Estabrooks, 1998; Hardy, 1978).
The term knowledge refers to knowing that can be communicated to others (Chinn & Kramer, 2008). Knowledge
is personal, involves patterns of recognition, and is a function of both the viewer and the phenomenon being
viewed (Newman, Sime & Corcoran-Perry, 1991). Knowing is also a dynamic process which refers to ways
of perceiving and understanding the self in the context of the environment. In a discipline such as nursing,
knowledge represents what is taken to be a shared understanding of the world as it is known by its members.
Knowledge is fundamental to reasoning and decision-making, and therefore central to professional practice.
According to Rycroft-Malone and Stetler (2004), knowledge can be categorized into two discrete categories:
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propositional and non-propositional. Propositional knowledge is formal and explicit, originates from research
and scholarship, and is primarily focused on generalizability. Non-propositional knowledge is informal and
implicit, is derived primarily from practice, consists of tacit or professional craft knowledge, and is linked to
the individual’s life experiences and cognitive resources that enables him or her to think and perform. Non-
propositional knowledge is not concerned with transferability (i. e., generalizability) beyond a particular situa-
tion. It is evident that multiple sources of both propositional and non-propositional knowledge are integrated
and relied upon within the nursing profession. In 1978, Carper identified four fundamental ways of knowing
(i. e., empirical, aesthetic, self-knowledge, ethical) and proposed the notion that multiple patterns of knowledge
are necessary if the diversity and scope of the nursing role is to be understood. In 2008, Chinn and Kramer sug-
gested emancipatory knowing as a fifth additional way of knowing that focused on social justice and human
rights.

Reflections on ways of knowing in nursing

Carper’s (1978) fundamental ways of knowing in nursing included empirical knowledge, aesthetics, personal
knowledge, and ethical knowledge. Empirical knowledge can be experiential knowledge from scientific inquiry
that provides objective evidence that is quantifiable and verifiable. When empirics are integrated into practice
it can demonstrate scientific competence. Aesthetics is sometimes referred to as the nature or “art” of knowing
in nursing as it uses empathy to gain knowledge about an individual’s experiences and creativity to formulate
a response to their situation. Personal knowledge comes from self-awareness which allows the nurse to un-
derstand his or her own responses, strengths, or weaknesses as well as how personal biases may influence the
quality of a nurse-patient relationship. The goal of developing ethical knowledge is to promote ethical prac-

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tice which can be cultivated through analysis of the circumstances that guide clinical decision-making. Ethical
knowing can be difficult because each person’s view of what is good or right may be different. Each type of
knowing is not a fixed entity but an evolving process (Carper, 1978).
The interaction of these concepts in practice calls for a shift from the ontological and epistemological as-
sumptions associated with the empirical medical model of care and moves nursing to a more flexible and
inclusive paradigm (Zander, 2007). Carper (1978) viewed these patterns or ways of knowing as separate but in-
terrelated concepts and proposed that they could be used to structure nursing education and evaluate nursing
practice. Within many nursing education programs, Carper’s framework is used to stimulate critical thinking
and encourage nursing students to reflect beyond the task-based nursing care that often dominates their focus
within clinical practicum settings (Carnago & Mast, 2015; Christensen, 2009). Emancipatory knowing is often
referred to as the fifth way of knowing (Chinn & Kramer, 2008; White, 1995) and provides an added element for
students to reflect on the socio-political climate potentially influencing their ability to provide comprehensive
nursing care.
In order to promote real-world application for both nursing students and nurse educators, each way of
knowing will first be defined, then applied in the context of both an acute care and a community-based bac-
calaureate clinical scenario. This paper is intended to challenge nursing students to develop their reflexivity
skills and conceptualize a deeper understanding of nursing practice beyond the task-based elements of the
care they provide.

Selected clinical placement scenarios

Scenario 1: Elementary school community placement

A nursing student is assigned a clinical placement in an elementary school for her community health nursing
course. A parent volunteer at the school tells the student that she will not be allowing her daughter in grade
six to receive the Human Papillomavirus Vaccine (HPV) since she believes this vaccine causes sterility and
promotes sexual promiscuity among students.

Scenario 2: International neurological acute care placement

A nursing student in an international placement in an under-resourced country had the opportunity to practice
in a private neurological medical ward. He is assigned a female patient who had been on the private ward for
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over a month, was diagnosed with metastatic brain lesions, and had a “Do Not Resuscitate” (DNR) order on
her chart. The patient’s endotracheal tube became misplaced causing her oxygen saturation to drop to 31 %.
A cardiac arrest ensued, with the medical team initiating cardiopulmonary resuscitation (CPR) despite the
presence of the DNR order. A normal sinus rhythm was re-established, however, a decision was made that a
new endotracheal tube would only be provided if it was to be purchased by the patient’s family.

Application of the ways of knowing in clinical practice

Empirics

Empirics as a way of knowing draws on the traditional assumption of science in that what is known is viewed
as accessible through the physical senses (Chinn & Kramer, 2008). Carper (1978) stated there is critical need
for knowledge in nursing that is systematically organized into general laws and theories for the purpose of de-
scribing, predicting, and explaining nursing phenomenon. Historically, Carper (1978) recognized that nursing
science did not demonstrate the same degree of empirical evidence as the “more mature sciences” (p. 14). She
went on to suggest that nursing had yet to decide on a scientific paradigm that would fully explain nursing
practice, recognizing the ongoing shifts from observational or descriptive forms of knowledge development
to more inclusive theoretical forms. “Thus, the first fundamental pattern of knowing in nursing is empirical,
factual, descriptive, and ultimately aimed at developing abstract and theoretical explanations” (Carper, 1978,
p. 15).
Empirical knowing is expressed in practice as scientific competence (Chinn & Kramer, 2008). Scientific com-
petence is grounded in scientific knowledge, including theory. Empiricist or positivist methods generally accept

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 Campbell et al. DE GRUYTER

the premise that knowledge begins with sense experiences such as observations and experiments (Schwandt,
2001). Empiric methods are often used to answer effectiveness questions and are used in pursuit of an objective
reality.

Community placement

In order to develop an understanding of the relevant empirical knowledge which may be helpful to support her
community placement, the nursing student researched reputable literature/resources surrounding HPV infec-
tion rates and vaccination risks/benefits from Centers for Disease Control and Prevention (2014), applicable
National Public Health Agencies, and the World Health Organization (2016). This factually-based knowledge
provided a foundation for a deeper reflection within the remaining ways of knowing.

International acute care placement

Although located in an international placement with a different health care system and limited guiding policies,
the student in the acute care placement gathered factual information about the neurological effects of metastatic
brain cancer and applicable nursing care from reputable sources. Considering the international nature of the
placement, the student also recognized the need to explore and reflect upon how care expectations may be
different from their home country and develop a reflexive understanding of the concept of culture shock.

Aesthetics

Carper (1978) acknowledged that because of the apprenticeship and imitative learning style that formed nursing
educations’ past, there was an initial reluctance to include aspects of knowing that were not the result of empir-
ical investigation. The aesthetic way of knowing was developed by Carper to go beyond empirical explanations
in order to account for the “intangible entities” in nursing (Zander, 2007). The aesthetics, or art of nursing, can
be difficult to define as aesthetics resides in an ontologic plane as it is expressed in the being-knowing of the
nurse (Chinn & Kramer, 2008). The art of nursing is found in the everyday nursing experiences and is demon-
strated in multiple forms of expression. Aesthetic knowing goes beyond the surface. It takes the nurse to the
‘meaning of the moment’. Aesthetics are the expressive, creative, empathic, and intuitive application of formal
knowledge situated in individual human experience and action (Chinn & Kramer, 2008). According to Carper,
aesthetic knowing assists the nurse to see the whole situation from a personal standpoint. Aesthetic knowing
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involves the deep appreciation of the meaning of a situation and calls for an inner creative response from the
nurse (Chinn & Kramer, 2008). As an art and as an action, aesthetics are what the nurse is able to provide for
the patient to help them cope with their situation. The art of nursing encompasses both motor and intellectual
skills. It is the “know how” of nursing (Stein, Corte, Colling, & Whall, 1998). In this way of knowing, the nurse
expresses the artfulness of nursing by the act of caring for individuals (Van Der Zalm & Bergum, 2000).
The multiple conceptualizations of the ‘art’ of nursing has been debated and presented over time. Although
Carper (1978) viewed the ways of knowing as separate though interrelated, Chinn and Kramer (2008) envi-
sioned aesthetics as both a separate knowledge form and as a synthesis of all of the ways of knowing. In their
model of nursing knowledge development, Chinn and Kramer (2008) state that aesthetics is difficult to define
as it “brings the concerns of being (ontology) and knowing (epistemology) together and can open doors for the
experience of the whole” (p. 216). Van Der Zalm and Bergum (2000) also state that one cannot discuss aesthetic
knowing without also referring to personal knowing which is needed for the development of moral knowledge.

Community placement

In an aim to incorporate aesthetic ways of knowing, the student aimed to discover the ‘meaning in the moment’
for the parent who had expressed concerns about the HPV vaccination. The student reflected on whether the
parent had all the facts related to the safety of HPV vaccine, and acknowledged the need to gently inquire about
the sources of information upon which the parent was relying, and their openness to consider more credible
sources. The student also recognized that this parent might be categorized as “The Unconvinced” according
to Keane et al.’s model (2005) because of her doubts, attitudes and conflicting beliefs about immunization.
Aesthetic knowing was also demonstrated through the student’s attention to mutual respect and goal to avoid
a debate in the hope of keeping the door open for future discussions.

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International acute care placement

The patient in this situation had been in a coma for two months and after the patient was resuscitated and re-
intubated, the family was anxious to communicate with health care providers regarding the patient’s prognosis.
Some family members thought the patient’s health status would improve and asked if the mother would walk
again. The student reflected on his discomfort and hesitancy in speaking with the family as there was not only
a language barrier and he did not want to be misunderstood, but some of the family did not understand the
patient’s dire prognosis. After consulting with the head nurse about what he would be able to say as a nurse
in this context, he recognized the needs of the family and he was able to approach the family with the patient’s
physician to clear up any misunderstanding about the patient’s prognosis. The student realized that when you
can’t directly communicate with people, it is much more difficult to enact the aesthetics way of knowing.

Personal knowledge

According to Carper (1978), “Personal knowledge as a fundamental pattern of knowing in nursing is the most
problematic, the most difficult to teach” (p. 18). Personal knowledge is concerned with knowing and under-
standing the individual self in a relationship that is subjective, concrete, and existential (Zander, 2007). Personal
knowledge is concerned with the inner experience of becoming a whole, aware, genuine self. It is through know-
ing the self that one can know others. Personal knowledge makes meaningful shared experiences possible. The
formal expressions of personal knowing are personal stories and autobiographies. These formal expressions
provide sources of deep reflection and shared understanding.
Personal knowledge does not require mediation only through language and this knowledge of self may be
enhanced through the use of art, poetry, and stories told in a manner which enables nurses to better understand
the patient and their world (White, 1995). In the personal knowledge pattern, the nurse does not approach the
patient as an object, but strives to develop an authentic personal relationship between two people. Personal
knowledge acknowledges that people are not fixed entities but are always in the process of “becoming” (Carper,
1978, p. 19). Finally, personal knowledge is the product of personal experiences that occur in practice when we
delve into the process of knowing the self and developing self-knowing through our encounters with others
(Chinn & Kramer, 2008).
More recently, Chinn and Kramer (2008) conceptualized that personal knowledge is expressed as mind-
body-spirit congruence. Personal knowledge is congruence between the authentic and the disclosed self (White,
1995). Personal knowledge involves deep inner reflection that can be found in solitude and it can also involve
being open to experience in the world with others. Personal knowledge is more recently viewed as the basis
of relationships in nursing. Rycroft-Malone and Stetler (2004) emphasized the centrality of the nurse-patient
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relationship as nursing is mediated through contact and relationships between nurses and their patients. The
centrality of the relationship, which is derived from self-knowledge, compliments that role of scientific evidence
and suggests that evidence is larger than scientific research.

Community placement

From a perspective of personal knowing, the student acknowledged that she grew up in a home with parents
who viewed immunization as safe, thus she was immunized for HPV when she was in grade six with no adverse
effects. The importance of immunization had also been reinforced in the curriculum content of her nursing
program. The student shared that she did have extended family members and friends who are opposed to
vaccines/immunizations but she believed that they were misinformed. In order to develop a whole, genuine
perceptive, the student attempted to place her own personal beliefs/knowledge surrounding immunization
into the context of how the parent’s upbringing and past experiences may have differed from her own.

International acute care placement

This student reflected on the personal knowledge that he is from a single-payer publicly funded healthcare
system where people are treated regarding their illness, not their ability to pay for services. In the context of
working in the Canadian health care system, he was also aware that he did not need to financially account for
resources used during caregiving activities. His personal knowing and development of a genuine self included
noting the distressing impact of being witness to delays in care (i. e., waiting for payment for an endotracheal
tube). As well, he reflected on the possibility that some of his distressing reactions in this clinical placement

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may have been the result of culture shock “the way things are done around here” and that some of his personal
viewpoints may have been influenced by experiencing a fee-for-service system.

Ethics

Ethical knowledge is abstract, conceptual, descriptive, discursive, and verbally communicated (Stein et al.,
1998). By including this way of knowing, Carper (1978) acknowledged the importance of societal norms and
ethical codes in nursing practice. “The ethical pattern of knowing in nursing requires an understanding of dif-
ferent philosophical positions regarding what is good, what ought to be desired, what is right “ (Carper, 1978,
p. 21). Ethical knowing guides and directs how nurses conduct their practice, what they view as important,
and what priorities require advocacy. Ethical knowing involves confronting and resolving conflicting values
and norms. Although there may be no satisfactory answer to an ethical dilemma, ethical knowing requires the
nurse to consider alternatives, some of which are more or less satisfactory.
Ethical knowledge is expressed in nursing actions when nurses ask themselves, “Is this right?” and “Is this
responsible?” (Chinn & Kramer, 2008; Newham, Curzio, Carr, & Terry, 2013). Nursing actions based on ethical
knowing can be observed by others, and the underlying ethical principles can then be examined. Ethical know-
ing does not describe or prescribe decisions but rather it provides insights about which choices are possible
and provides direction toward choices that are sound, responsible, and just (Chinn & Kramer, 2008; Newham
et al., 2013).
With regard to the ethical way of knowing, Carper was one of the earliest nursing writers to speak of the
situational and relational importance of moral decision-making (White, 1995). Carper presented a complex
picture of ethical knowing which is reflective of the multidimensional components of ethics. White (1995) sug-
gested that the earlier focus on individual justice, with its male orientation, has evolved into a more commonly
adopted female orientation which included a contextual, relational, and care orientation that focuses on the col-
lective social and moral good. Since Carper introduced these patterns, the ethical discussion has moved from a
duty of care to an ethic of care (White, 1995). Carper also alluded to the moral distress and moral residue that
may follow if nurses find themselves in conflict about their moral choices (Silva, Sorrell, & Sorrell, 1995).

Community placement

In terms of ethical knowing, the student reflected on two competing ethical principles, with the potential for
this situation to lead to an ethical dilemma. For example, the principle of ‘respecting individual autonomy’ in
this scenario suggested that people should be provided with the information so they can make an informed
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decision, with the right to refuse the immunization. However, the student also considered the ethical principle
of ‘beneficence’ (e. g., the aim to prevent or protect from harm), suggesting that it is in the best interest of society
to reduce the spread of HPV in the community, and potentially protect the grade six students from experiencing
harm at a later date.

International acute care placement

After his experiences on the neurological medical ward, the student reflected on his potential risk for moral
distress due to two issues: (1) the patient was resuscitated despite the DNR and (2) the patient would have died
if the family could not afford an inexpensive endotracheal tube. The student used his post-conference to share
his thoughts on the ethical challenges of caring for a patient who had a DNR that was not followed and his fear
that the family could not afford the endotracheal tube. Some of his reflections included perceptions that the
family was keeping the patient alive until they were ready to “let her go,” which he felt interfered with what
he thought was the ethical value and responsibility of providing “safe, compassionate, competent, and ethical
care” to the patient (Canadian Nurses Association, 2008, p. 2). As well he believed the medical and nursing
staff did not respect the patient’s and family’s wishes for a DNR status which is in conflict with International
Council of Nurses’ position statement regarding the provision end of life care to patients and their families
which includes respecting the patient’s will and ethical standards and cultural norms in end of life care (2012).

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Emancipatory knowing

Chinn and Kramer (2008, 2015) contributed emancipatory knowing as a fifth pattern or way of knowing. Eman-
cipatory knowing requires nurses to critically examine social problems and to promote social change to address
any injustices. The use of emancipatory knowing is not new to nursing, with Florence Nightingale a leader in
promoting social reforms to improve patient care with a particular focus on the vulnerable (McDonald, 2014).
According to the International Council of Nurses (2011) Statement on Nurses and Human Rights, “Nurses deal
with human rights issues daily, in all aspects of their professional role” and “to prepare nurses to adequately
address human rights, human rights issues and the nurses’ role need to be included in all levels of nursing
education programmes” (p. 2).
Chinn and Kramer proposed that nursing care is most effective when all five ways of knowing are integrated
(Chinn & Kramer, 2015). Emancipatory knowing builds on the other ways of knowing by asking the nurse to re-
flect on the social context behind the client’s situation and to consider actions that will help the broader society.
According to Chinn and Kramer (2015), while such praxis will not arise out of every nursing encounter, nurses
should be aware of and reflect on situations of injustice, promote the awareness of others, and take broader ac-
tions to improve such situations when possible. Ethics focuses on moral obligation and making judgements on
what is the right and responsible action in a particular situation. Emancipatory knowing, in contrast, explores
the inequity of the situation, the causes behind any injustice, and the changes that are needed at a societal level
to prevent such situations in the future (Chinn & Kramer, 2015).

Community placement

In the context of emancipatory knowing, this student considered the fact that male students were not receiv-
ing the HPV immunization in this jurisdiction for free despite recent research showing HPV has a role in the
increasing incidence of mouth, nose, throat and anal cancers (Centers for Disease Control & Prevention, 2014).
The initial program was meant to reduce cervical cancer and thus only females were the target population. Since
HPV vaccine is very expensive, it is less likely that males from lower-income families would receive this pro-
tection. The student had the opportunity to reflect on what the nursing profession could do to try and address
this apparent social injustice.

International acute care placement

From an emancipatory knowing perspective, the student in the international placement understood that when
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resources in a country are scarce there are some difficult decisions to be made. The student examined the Gross
National Product spending on the military and on healthcare in the placement country. As well, he reflected
on the need for government policies to address social inequity. He also realized that he was not going to be
able the change anything about the healthcare system in the host country in a five-week placement, but the
experience did open his eyes regarding basic human rights and how unconscious ideology leads to acceptance
of inequity. The student also reflected on the notion that he would not be comfortable living and/or working
in a place that didn’t provide healthcare as a right of a citizen in a civil society. See Table 1 for an overview of
the application of the ways of knowing framework.

Table 1: Application of ways of knowing to two clinical practicum placements.

Elementary School Community Placement International Acute Care Placement

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 Campbell et al.
A nursing student is fulfilling a health
promotion role as part of a clinical placement
in an elementary school for her community
health nursing course. A parent volunteer at
the school tells the student that she will not
be allowing her daughter to receive the
Human Papillomavirus Vaccine (HPV),
routinely offered for free at the school to
twelve year old girls, since she believes this
vaccine causes sterility and promotes sexual
promiscuity among students. The nursing
student ponders how best to respond.
Empirics Elementary School Community Placement
– Develop an understanding of relevant
empirical/scientific knowledge
– Research reputable literature/resources
surrounding HPV infection rates and
vaccination risks/benefits
– Target a variety of high quality information
sources i. e., Centers for Disease Control and
Prevention, National Public Health Agencies,
World Health Organization.
Aesthetics Elementary School Community Placement
– Discover the ‘meaning in the moment’ for
the parent who had expressed concerns
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about the HPV vaccination
– Acknowledges the need to gently inquire
about the sources of information upon which
the parent was relying, and their openness to
consider more credible sources
– Attend to the goal of mutual respect and
avoid conflict or debate in the hope of
keeping the door open for future discussions.
Personal Knowledge Elementary School Community Placement
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A nursing student in an international
placement in an under-resourced country
had the opportunity to practice in a private
neurological medical ward. He is assigned a
female patient who had been on the private
ward for over two months, was diagnosed
with metastatic brain lesions, and had a “Do
Not Resuscitate” (DNR) order on her chart.
The patient’s endotracheal tube became
misplaced causing her oxygen saturation to
drop to 31 %. A cardiac arrest ensued, with
the medical team initiated cardiopulmonary
resuscitation (CPR) despite the DNR order. A
normal sinus rhythm was re-established,
however, a decision was made that a new
endotracheal tube would only be provided if
it was purchased by the patient’s family.
International Acute Care Placement
– Acknowledge the challenges of an
international context, different health care
system, limited guiding policies, and
potential for culture shock
– Gathered factual information about the
neurological effects of metastatic brain cancer
and applicable nursing care from reputable
high quality sources (i. e. peer-reviewed
journal articles not more than five years old).
– Explore and reflect upon how care
expectations may be different from their
home country
International Acute Care Placement.
– Reflect on personal discomfort and
hesitancy in speaking with the family where
a language barrier is apparent
– Speak with the head nurse about what
would be an appropriate response in the
context of this health care system
– Recognize the needs of the family and
approach the family with the patient’s
physician to clear up any misunderstanding
about the patient’s prognosis.
– Reflect on the difficulties enacting aesthetic
ways of knowing when direct verbal
communicate with patients and their family
members is not possible due to language
barriers
International Acute Care Placement
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 DE GRUYTER Campbell et al.

– Acknowledge own personal beliefs based
on an upbringing which valued
immunization as safe
– Recognize and reflect on how the
importance of immunization has been
reinforced in the curriculum content of the
nursing education program.
– Make an effort to place own personal
beliefs/knowledge surrounding
immunization into the context of how this
parent’s upbringing and past experiences
may have differed from her own
– Reflect on the personal knowledge that this
student is from a single-payer publicly
funded healthcare system where people are
treated regarding their illness, not their
ability to pay for services
– Note the potential distressing impact of
being witness to delays in care (i. e., waiting
for payment for endotracheal tube), and the
role that culture shock may play

Ethics Elementary School Community Placement International Acute Care Placement

– Reflection on two competing ethical
principles, with the potential for this
situation to lead to an ethical dilemma
– Consider the ethical principle ‘respecting
individual autonomy’ suggesting that people
should be provided with the needed
information to make an informed decision,
but retain the right to refuse the HPV
immunization
– Also consider the ethical principle of
‘utility’ (for the greater good), suggesting that
from a community health perspective, it is in
the best interest of society for eligible persons
to receive the vaccine in order to reduce the
spread of HPV in the community
– Reflect on the potential risks for moral
distress, and share thoughts on the ethical
challenges of caring for a patient in a different
healthcare system where care is delivered
based on the ability to pay
– Specific reflections could include the
perception that the family was keeping the
patient alive until they were ready to “let her
go,” which the student felt interfered with
the ethical value and responsibility of
providing “safe, compassionate, competent,
and ethical care” to the patient

Emancipatory Elementary School Community Placement International Acute Care Placement

– Consider the fact that male students are not
eligible to receive the HPV vaccine for free
in this jurisdiction despite recent research
showing HPV has a role in the increasing
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– Consider the dilemma when resources in a
country are scarce, some difficult decisions
must be made
– Examine the Gross National Product

incidence of mouth, nose, throat and anal
cancers (CDC, 2014)
– Discuss the concern regarding the high cost
of the HPV vaccine, less likelihood that males
from lower-income families will receive this
protection.
– Reflects on how the nursing profession
could advocate to try and address this
apparent social injustice.
spending on the military and on healthcare in
the placement country
– Reflect on the need for government policies
to address social inequity
– Recognize the limits of enacting change
within a five-week placement, but develop an
awareness of how unconscious ideology can
lead to the acceptance of inequity.

Conclusion
The patterns of knowing articulated by Carper (1978) and Chinn and Kramer (2015) provide a framework with
which to teach and/or learn the constructs which make up nursing practice. Frameworks help students concep-
tualize and critically reflect upon important processes in professional learning needed for nursing. One major
criticism of Carper’s work is that it is not easily understood by undergraduate nursing students, making it chal-
lenging for faculty and students to use in practice. This paper has provided practical descriptions and concrete
examples to assist students to incorporate the five ways of knowing into their reflective practice and thereby
more fully develop their construct of nursing.
Carper has laid the foundation for continuing development of nursing knowledge as she took nursing’s
epistemology from an almost purely scientific perspective, to one that encompassed and celebrated other forms
of knowing. That the ways of knowing are still debated forty years after their introduction is evidence that these

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 Campbell et al. DE GRUYTER

patterns have played a critical role in informing the science and practice of nursing. This growth will not result
in a fixed product that will be called “nursing knowledge” as nursing is a profession that will continue to evolve.
To quote Carper,

Nursing thus depends on the scientific knowledge of human behaviour in health and illness, the aesthetic
perception of significant human experience, a personal understanding of the unique individuality of the
self and the capacity to make choices within concrete situations involving particular moral judgments.
(Carper, 1978, p. 22)

Nearly two decades after Carper wrote of the four patterns of knowing to address the “who”, “how”, and
“what” of nursing practice, the emancipatory pattern was developed to address the “wherein”. The emanci-
patory pattern moves from the relationship between the patient and the nurse into the wider context of the
environment in which healthcare is practiced.

References
Alligood, M., & Chong Choi, E. (1998). Evolution of nursing theory development. In M. Alligood & M. Tomey (Eds.), Nursing theorists and their
work (4th ed., pp. 55–66). St Louis, MO: Mosby.
Boud, D. (2010). Relocating reflection in the context of practice. In H. Bradbury, N. Frost, S. Kilminister, & M. Zukas (Eds.), Beyond reflective
practice: New approaches to professional lifelong learning (pp. 25–36). Abingdon: Routledge.
Canadian Nurses Association. (2008). Code of ethics. Retrieved from https://www.cna-aiic.ca/~/media/cna/files/en/codeofethics.pdf
Carnago, L., & Mast, M. (2015). Using ways of knowing to guide emergency nursing practice. Journal of Emergency Nursing, 41, 387–390.
Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–24.
Centers for Disease Control and Prevention. (2014). What parents should know about HPV vaccine safety and effectiveness. Retrieved from
https://www.cdc.gov/vaccines/who/teens/vaccines/vaccine-safety.pdf
Chinn, P. L., & Kramer, M. K. (2008). Integrated theory and knowledge development in nursing (7th ed.). St Louis, MO: Mosby Elsevier.
Chinn, P. L., & Kramer, M. K. (2015). Knowledge development in nursing: Theory and process (9th ed.). St Louis, MO: Mosby Elsevier.
Christensen, M. (2009). Advancing practice in critical care: A model of knowledge integration. Nursing in Critical Care, 14(2), 86–94.
doi:10.1111/j.1478-5153.2008.00318.x
Estabrooks, C. (1998). Will evidence-based nursing practice make practice perfect?. Canadian Journal of Nursing Research, 30(1), 15–36.
Fook, J., & Gardner, F. (2007). Practising critical reflection: A resource handbook. Maidenhead: Open University Press.
Hardy, M. (1978). Perspectives on nursing theory. In P. Reeed, N. Shearer, & L. Nicoll (Eds.), Perspectives on nursing theory (4th ed., pp. 121–129).
Philadelphia. PA: Lippincott.
Hargreaves, J. (2009). Voices from the past: Professional discourse and reflective practice. In H. Bradbury, N. Frost, S. Kilminister, & M. Zukas
(Eds.), Beyond reflective practice: New approaches to professional lifelong learning (pp. 84). Abingdon: Routledge.
Horsfall, J., Cleary, M., & Hunt, G. (2011). Developing a pedagogy for nursing teaching-learning. Nurse Education Today, 32, 930–933.
Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd

Hunter, L. (2008). Stories as integrated patterns of knowing in nursing education. International Journal of Nursing Education Scholarship, 5(1),
1–13. doi: org/10.2202/1548-923X.1630
International Council of Nurses. (2011). Statement on nurses and human rights. Retrieved from
http://www.icn.ch/images/stories/documents/publications/position_statements/E10_Nurses_Human_Rights.pdf
International Council of Nurses. (2012). Statement on nurses’ role in providing care to dying patients and their families. Retrieved from
http://www.icn.ch/images/stories/documents/publications/position_statements/A12_Nurses_Role_Care_Dying_Patients.pdf
Keane, et al. (2005). Confidence in vaccinations: A parent model. Vaccine, 23, 2486–2493.
McDonald, L. (2014). Florence Nightingale at first hand. London, UK: Bloomsbury Continuum.
McGovern, B., Lapum, J., Clune, L., & Schindel, M. L. (2013). Theoretical framing of high-fidelity simulation with Carper’s fundamental pat-
terns of knowing in nursing. Journal of Nursing Education, 52(1), 46–49.
Newham, R., Curzio, J., Carr, G., & Terry, L. (2013). Contemporary nursing wisdom in the UK and ethical knowing: Difficulties in conceptualiz-
ing the ethics of nursing. Nursing Philosophy, 15, 50–56.
Newman, M., Sime, A. M., & Corcoran-Perry, S. (1991). The focus of the discipline of nursing. In P. Reed, N. Shearer, & L. Nicoll (Eds.), Perspec-
tives on nursing theory (4th ed., pp. 315–320). Philadelphia, PA: Lippincott.
Rycroft-Malone, J., & Stetler, C. (2004). Commentary on evidence, research, knowledge: A call for conceptual clarity: Shannon Scott-Findlay &
Carolee Pollock. Worldviews on Evidence-Based Nursing, 1(2), 98–101. doi:10.1111/j.1741-6787.2004.04031.x
Schwandt, T. (2001). Dictionary of qualitative inquiry (2nd ed.). London: Sage Publications.
Selanders, L. C. (1995). Florence Nightingale: An environmental adaptation theory. In C. Metzger-McQuiston & A. Webb (Eds.), Foundations of
nursing theory (pp. 417–458). London: Sage Publications.
Silva, M., Sorrell, J., & Sorrell, C. (1995). From Carper’s patterns of knowing to way of being: An ontological shift. Advances in Nursing Science,
18(1), 1–13.
Small, H. (1999). Florence Nightingale: Avenging angel. New York: St Martin’s Press.
Stein, K., Corte, C., Colling, K., & Whall, A. (1998). A theoretical analysis of Carper’s ways of knowing using a model of social cognition. Schol-
arly Inquiry for Nursing Practice: An International Journal, 12(1), 43–65.
Van Der Zalm, J., & Bergum, V. (2000). Hermeneutic-phenomenology: Providing living knowledge for nursing practice. Journal of Advanced
Nursing, 31(1), 211–218.

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 DE GRUYTER Campbell et al.

Wagner, L., & Christensen, S. (2015). Establishment of a short-term global health nursing education experience: Impact of students’ ways of
knowing. Journal of Nursing Education, 54(5), 295–299. doi:10.3928/1484834-20150417-09
White, J. (1995). Patterns of knowing: Review, critique, and update. Advances in Nursing Science, 17(4), 73–86. doi:10.1097/00012272-199506000-
00007
World Health Organization. (2016). Safety of HPV vaccines. Retrieved from http://www.who.int/vaccine_safety/committee/topics/hpv/en/
Zander, P. (2007). Ways of knowing in nursing: The historical evolution of a concept. The Journal of Theory Construction and Testing, 11(1), 7–11.
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