anexos 1.1

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CHAPTER 3
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Fundamental Patterns of
Knowing in Nursing
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Barbara A. Carper, RN, EdD
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It is the general conception of any field of Identifying Patterns
inquiry that ultimately determines the kind
of Knowing
of knowledge
the Learning,
field aims to develop
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& Bartlett
LLC as well
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as theSALE
mannerOR
in which
that knowledge is to
Four fundamental
knowing
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OR
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be organized, tested, and applied. The body have been identified from an analysis of the
of knowledge that serves as the rationale for conceptual and syntactical structure of nursnursing practice has patterns, forms, and ing knowledge.1 The four patterns are distinstructure that serve as horizons of expecta- guished according to logical type of meaning
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and exemplify characteristic ways of and designated as (1) empirics, the science
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thinking
about phenomena. Understanding
of nursing; (2) esthetics, the art of nursing;
these patterns is essential for the teaching and (3) the component of a personal knowledge
learning of nursing. Such an understanding in nursing; and (4) ethics, the component of
does not extend the range of knowledge, but moral knowledge in nursing.
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BartletttoLearning,
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rather involves
critical
the ques- LLC
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FORtoSALE
ORwhat
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tion of what
it means
know and
kinds Empirics: The Science of Nursing
of knowledge are held to be of most value in
The term nursing science was rarely used
the discipline of nursing.
in the literature until the late 1950s. However,
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Source: Carper, B. A. (1978). Fundamental patterns of knowing in nursing. ANS, 1 (1): 13–24.
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Reprinted
with permission
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23
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Chapter 3: Fundamental Patterns of Knowing in Nursing
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since that time, there has been an increas- observed phenomena and may ultimately
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NOT one
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might
even
sayDISTRIBUTION
a sense permit more accurate prediction
and conof urgency, regarding the development of trol of them. However, this is a matter to be
a body of empirical knowledge specific to determined by research designed to test the
nursing. There seems to be general agree- validity of such explanatory concepts in the
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ment&that
there isLearning,
a critical need
for knowl- context of relevant
empirical
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edge about
empirical
world, knowledge
New Perspectives
What
seems
be of
that is systematically organized into general paramount importance, at least at this stage
laws and theories for the purpose of describ- in the development of nursing science, is that
ing, explaining, and predicting phenomena these preparadigm conceptual structures and
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special concern
theoretical
models present
new perspectives
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ing. Most theory development and research for considering the familiar phenomena of
efforts are primarily engaged in seeking and health and illness in relation to the human
generating explanations that are systematic life process; as such, they can and should be
and controllable by factual evidence and that legitimately counted as discoveries in the
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can be used
the organization
andLearning,
classifica- discipline.
The representation
of health
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tion of knowledge.
more than the absence of disease
a crucial
The pattern of knowing that is generally change; it permits health to be thought of as
designated as “nursing science” does not a dynamic state or process that changes over
presently exhibit the same degree of highly a given period of time and varies according
integrated
abstract
and systematic
rather&
than
a static either/or
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tions SALE
characteristic
of the more mature sci- entity. The conceptual
in OR
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makes
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ences, although nursing literature reflects this it possible to raise questions that previously
as an ideal form. Clearly, there are a number would have been literally unintelligible.
of coexisting, and in a few instances competThe discovery that one can usefully conconceptual
structures—none of which
ceptualize
health as something
that
normally
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has achieved the status of what Kuhn calls a ranges along a continuum has led to attempts
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scientific paradigm. That is, no single con- to observe, describe, and classify variations in
ceptual structure is as yet generally accepted health, or levels of wellness, as expressions of
as an example of actual scientific practice a human being’s relationship to the internal
“which include[s] law, theory, application, and external environments. Related research
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and instrumentation together . . . [and] has sought to identify behavioral responses,
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. . . provide[s] models from which spring both physiological and psychological, that
particular coherent traditions of scientific may serve as cues by which one can infer the
2(p10)
It could be argued that some range of normal variations of health. It has
research.”
of these conceptual structures seem to have also attempted to identify and categorize
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greater potential than others for providing significant etiological factors that serve to
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explanations
account for promote orNOT
inhibitFOR
changes
in health
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Identifying Patterns of Knowing
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Current Stages The science of nursing at conditions for the normal development of
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present exhibits aspects of both the “natu- an individual.
Thus, the first fundamental pattern of
ral history stage of inquiry” and the “stage
of deductively formulated theory.” The task knowing in nursing is empirical, factual,
of the natural history stage is primarily the descriptive, and ultimately aimed at devel© Jones
& Bartlett
Learning,ofLLC
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Learning, LLC
and theoretical
explanations.
description
and classification
phenomena oping abstract
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discursively
formulated,
and
that are,
generally
ascertainable by It is exemplary,
3
direct observation and inspection, but cur- publicly verifiable.
rent nursing literature clearly reflects a shift
from this descriptive and classification form Esthetics: The Art of Nursing
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Learning,
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Few,&ifBartlett
indeed any,
familiar with
the proincreasinglyLLC
theoretical analysis, which ©
is Jones
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directed toward seeking, or inventing, expla- fessional literature would deny that primary
nations to account for observed and classified emphasis is placed on the development of
empirical facts. This shift is reflected in the the science of nursing. One is almost led to
change from a largely observational vocabu- believe that the only valid and reliable knowlJones
Bartlettvocabulary
Learning, LLC
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edge is that which is empirical,
lary to a ©
new,
more&theoretical
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There
whose terms
a distinct
meaning
and tively descriptive, and generalizable.
definition only in the context of the corre- seems to be a self-conscious reluctance to
extend the term knowledge to include those
sponding explanatory theory.
Explanations in the several open-system aspects of knowing in nursing that are not
There
conceptual
models
tend to take
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Jones &investigation.
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4
what
might
be described
as a
commonly
labeled
or teleological. is, nonetheless,
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For example, the system models explain a tacit admission that nursing is, at least in part,
person’s level of wellness at any particular an art. Not much effort is made to elaborate
point in time as a function of current and or to make explicit this esthetic pattern of
knowing
nursing—other
than to
associate
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Learning, effects
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or her internal and external environments. vaguely the “art” with the general category of
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The concept of adaptation is central to this manual and/or technical skills involved in
type of explanation. Adaptation is seen nursing practice.
as crucial in the process of responding to
Perhaps this reluctance to acknowledge the
environmental demands (usually classi- esthetic component as a fundamental pattern
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fied as stressors) and enables an individual of knowing in nursing originates in the vigorNOT FOR SALE OR DISTRIBU
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to maintain or reestablish the steady state, ous efforts made in the not-so-distant past
which is designated as the goal of the system. to exorcise the image of the apprentice-type
The developmental models often exhibit a educational system. Within the apprentice
more genetic type of explanation in that system, the art of nursing was closely associ© Jones
& Bartlett Learning, LLC
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certain events, the developmental tasks, are ated with an imitative learning style and the
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believed
to beOR
causally
relevant or necessary acquisitionNOT
of knowledge
by accumulation
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Chapter 3: Fundamental Patterns of Knowing in Nursing
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of unrationalized experiences. Another likely exemplary and leads us to acknowledge that
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source of reluctance is that the definition of “knowledge—genuine knowledge, underthe term art has been excessively and inap- standing—is considerably wider than our
7(p23)
discourse.”
propriately restricted.
For Wiedenbach, the art of nursing is
Weitz suggests that art is too complex and
5
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Jonesthe&action
Bartlett
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takenLearning,
to provariable to be reduced to a single definition. made visible©through
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To conceive
taskDISTRIBUTION
of esthetic theory as defi- vide whatever
the patient
requiresOR
to restore
nition, he says, is logically doomed to failure or extend his [sic] ability to cope with the
8
in that what is called art has no common demands of his [sic] situation, but the action
properties—only recognizable similarities. taken, to have an esthetic quality, requires
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Learning,
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standing and application of the concept of art ate object—the patient’s behavior—into a
and esthetic meaning makes possible a wider direct, nonmediated perception of what is
consideration of conditions, situations, and significant in it—that is, what need is actuexperiences in nursing that may properly be ally being expressed by the behavior. This
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of the need expressed
is not only
called esthetic,
including
the creative
pro- perception
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by FOR
the nurse
cess of discovery
in theSALE
empirical
of responsible for the action taken
but reflected in it.
knowing.
The esthetic process described by
Esthetics Versus Scientific Meaning Despite this open texture of the concept of art, Wiedenbach resembles what Dewey refers
between
recognition
and
esthetic
meaningsLearning,
can be distinguished
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9
According
to Dewey,
those SALE
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in several
important aspects. perception.NOT
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The recognition “that art is expressive rather nition serves the purpose of identification
than merely formal or descriptive,” accord- and is satisfied when a name tag or label is
ing to Rader, “is about as well established as attached according to some stereotype or
6(p xvi)
previously
formed scheme
of classification.
fact in the LLC
whole field of esthetics.” © Jones
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An esthetic experience involves the creation Perception, however, goes beyond recogniNOT FOR SALE OR DISTRIBUTION
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and/or appreciation of a singular, particular, tion in that it includes an active gathering
subjective expression of imagined possibili- together of details and scattered particulars
ties or equivalent realities that “resists projec- into an experienced whole for the purpose of
7
tion into the discursive form of language.” seeing what is there. It is perception rather
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Knowledge gained by empirical description than mere recognition that results in a unity
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is discursively formulated and publicly veri- of ends and means that gives the action taken
fiable. The knowledge gained by subjective an esthetic quality.
acquaintance, the direct feeling of experience,
Orem speaks of the art of nursing as
defines discursive formulation. Although an being “expressed by the individual nurse
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it remains
specific
and unique rather than ing and providing
nursing
that OR
is effective
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10(p155)
27
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The art of nursing same time, increased awareness of the variand satisfying.”
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is creative in that it requires OR
development
ety of subjective experiences
will FOR
heighten
of the ability to “envision valid modes of the complexity and difficulty of the decision
helping in relation to ‘results’ which are making involved.
10(p69)
This again invokes
appropriate.”
The design of nursing care must be accom© Jones
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Dewey’s sense of a perceived unity between panied by what
Langer&refers
to as sense
of
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taken
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its result—a perception form, the sense
of FOR
“structure,
articulation,
a
9
of the means of the end as an organic whole. whole resulting from the relation of mutually
The experience of helping must be perceived dependent factors, or more precisely, the way
7(p16)
The design, if
and designed as an integral component of its the whole is put together.”
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Learning,
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rather than conceived sepaNOT FOR SALE OR
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rately as an independent action imposed on perception of the balance, rhythm, proporan independent subject. Perhaps this is what tion, and unity of what is done in relation to
is meant by the concept of nursing the whole the dynamic integration and articulation of
patient or total patient care. If so, what are the the whole. “The doing may be energetic, and
Learning,
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the undergoing may be acute
intense,”
qualities ©
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a design LLC
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are related
to
for nursing
care FOR
that eliminate
would
min- Dewey says, but “unless they
imize the fragmentation of means and ends? each other to form a whole,” what is done
becomes merely a matter of mechanical rou9
Esthetic Pattern of Knowing
tine or of caprice.
is, the capacity
The esthetic
pattern of
nursing
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ticipating
in OR
or vicariously
experiencing involves theNOT
perception
abstracted
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another’s feelings—is an important mode in lars as distinguished from the recognition of
the esthetic pattern of knowing. One gains abstracted universals. It is the knowing of a
knowledge of another person’s singular, unique particular rather than an exemplary
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11,12
Empathy is controlled or
acquaintance.
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moderated by psychic distance or detach- The Component of Personal
ment in order to apprehend and abstract Knowledge
Personal knowledge as a fundamental
what we are attending to and in this sense
is objective. The more skilled the nurse pattern of knowing in nursing is the most
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becomes in perceiving and empathizing problematic, the most difficult to master and
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with the lives of others, the more knowledge to teach. At the same time, it is perhaps the
or understanding will be gained of alternate pattern most essential to understanding the
modes of perceiving reality. The nurse will meaning of health in terms of individual wellthereby have available a larger repertoire of being. Nursing considered as an interpersonal
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choices in designing and providing nursing process involves interactions, relationships,
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the nurse
the
care that
is effective
and satisfying. At the and transactions
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Chapter 3: Fundamental Patterns of Knowing in Nursing
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Maslow refers to this sacrifice of form as
patient-client. Mitchell points out that “there
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is growing evidence that the quality of inter- embodying a more efficient perception of
personal contacts has an influence on a per- reality in that reality is not generalized nor
son’s becoming ill, coping with illness and predetermined by a complex of concepts,
13(p4950)
15
Certainly the phrase expectations, beliefs, and stereotypes. This
becoming well.”
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use of
self,” whichLLC
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ambiNOT FOR
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increasingly
in the literature, guity, vagueness,
discrepancy
of oneself
implies that the way in which nurses view and others. The risk of commitment involved
their own selves and the client is of primary in personal knowledge is what Polanyi calls
concern in any therapeutic relationship.
the “passionate participation in the act of
16(p17)
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Personal knowledge
knowing.”
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The nurse in the therapeutic
use of self
knowing, encountering, and actualizing of
the concrete, individual self. One does not rejects approaching the patient–client as
know about the self; one strives simply to an object and strives instead to actualize
know the self. This knowing is a standing in an authentic personal relationship between
© another
Jones human
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considered
relation to
beingLearning,
and con- two
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incorporating
fronting that
human
as aOR
person.
This as an integrated, open system
“I–Thou” encounter is unmediated by con- movement toward growth and fulfillment
ceptual categories or particulars abstracted of human potential. An authentic personal
14
from complex organic wholes. The relation relation requires the acceptance of others in
is one
reciprocity,
a state of being
to create&themselves
and the
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not aDISTRIBUTION
fixed
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only be actualized. Such personal knowing entity, but constantly engaged in the process
extends not only to other selves but also to of becoming. How then should the nurse recrelations with one’s own self.
oncile this with the social and/or professional
It requires what
responsibility
to control
and manipulate
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LLCBuber refers to as the sac© Jones
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rifice of form, that is, categories or classifica- environmental variables and even the behavNOT FOR SALE OR DISTRIBUTION
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tions, for a knowing of infinite possibilities, ior of the person who is a patient in order to
as well as the risk of total commitment.
maintain or restore a steady state? If a human
being is assumed to be free to choose and
Even as a melody is not composed
chooses behavior outside of accepted norms,
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of tones, nor a verse of words, nor a
how will this affect the action taken in the
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statue of lines-one must pull and tear
therapeutic use of self by the nurse? What
to turn a unity into a multiplicity—
choices must the nurse make in order to
so it is with the human being to
know another self in an authentic relation
whom I say You. . . . I have to do this
apart from the category of patient, even when
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Bartlett Learning, LLC
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again and again; but immediately he
categorizing for the purpose of treatment is
14(p59)
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no longer
essential to NOT
the process
nursing?
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Identifying Patterns of Knowing
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Assumptions regarding human nature, within the complex context of modern health
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McKay observes, “Range from the existen- care. These choices raise fundamental questialist to the cybernetic, from the idea of an tions about morally right and wrong action
information processing machine to one of in connection with the care and treatment of
17(p399)
Many of illness and the promotion of health. Moral
a many splendored being.”
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these assumptions incorporate in one form dilemmas arise
in situations
of ambiguity
and
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or another
notion
that there is, for all uncertainty,NOT
when FOR
the consequences
one’s
individuals, a characteristic state which actions are difficult to predict and traditional
they, by virtue of membership in the species, principles and ethical codes offer no help or
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Ethics: The Moral Component
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According to Berthold, “Goals are, of certain sorts of value questions about what
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course, value
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Dickoff, James, and Wiedenbach also call more involved in the making of what are
attention to the need to be aware that the commonly thought to be factual statements
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standard
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[and] . . . entails taking them as values— requires an understanding of different philothat is, signifies conceiving these goal con- sophical positions regarding what is good,
tents as situations worthy to be brought what ought to be desired, what is right; of dif19(p422)LLC
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For example, a common goal of nursing with the complexities of moral judgments;
care in relation to the maintenance or resto- and of various orientations to the notion of
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attitude to
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situations.
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themselves at the earliest possible moment what is involved in making moral choices and
or to&enable
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The
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The more sensitive teachers and
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Differences in normative judgments
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explicit they are about the norms that
as to what constitutes a “healthy” state of
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Slote suggests that the persistence of dispotential consequences, the more
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cation of cluster terms, such as health, is
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Using Patterns of Knowing
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Using NOT
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another human being involves becoming
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the capacity
to perceive
and
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subjective
othtered in the day-to-day doing and teaching of ers and to imaginatively project the effects
nursing, but it represents a personal convic- of nursing actions on their lives becomes a
tion that there is a need to examine the kinds necessary skill.
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of human behavior in health
Understanding four fundamental patterns of and in illness, the esthetic perception of
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ness of the complexity and diversity of nurs- understanding of the unique individuality
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of the self, and the capacity to
choices
Each pattern
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particusary for achieving mastery in the discipline, lar moral judgments. Each of these separate
but none of them alone should be considered but interrelated and interdependent fundasufficient. Neither are they mutually exclu- mental patterns of knowing should be taught
sive.&The
teaching
and learning
of one pat- and understood
according
to its distinctive
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tern
do
not
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the
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cally organized into theoretical explanations
The&
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ness, but creative imagination also plays its ing are summarized as (1) the conclusions
part in the syntax of discovery in science, as of the discipline conceived as subject matter
well as in developing the ability to imagine the cannot be taught or learned without referconsequences of alternative moral choices.
ence to the structure of the discipline—the
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Personal
knowledge
is essentialLearning,
for ethi- representative
concepts and methods of
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cal choices
in that
moral
actionOR
presupposes
inquiry that determine the kind of knowlpersonal maturity and freedom. If the goals edge gained and limit its meaning, scope,
of nursing are to be more than conformance and validity; (2) each of the fundamental
to unexamined norms, if the “ought” is not patterns of knowing represents a necessary
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to be&determined
simply on theLLC
basis of what but not complete
approach to the problems
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6. Rader, M. “Introduction: The Meaning
and questions in the discipline; and (3) all
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of Art” in Rader, M., ed. NOT
A Modern
Book
knowledge is subject to change and revision.
of Esthetics, 3rd ed. (New York: Holt,
Every solution of an existing problem raises
Rinehart and Winston, 1960).
new and unsolved questions. These new and
7. Langer, S. K. Problems of Art (New
as yet unsolved problems require, at times,
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Bartlett
Learning,
LLC conJonesScribner
& Bartlett
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York: ©
Charles
andLearning,
Sons,
new&methods
of inquiry
and different
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1957). NOT FOR SALE OR DISTRIBUTION
ceptual
structures;
change the shape and
8. Wiedenbach, E. Clinical Nursing:
patterns of knowing. With each change in the
A Helping Art (New York: Springer
shape of knowledge, teaching and learning
Publishing Co., Inc., 1964).
require looking for different points of contact
© Jones & Bartlettand
Learning,
LLC
© Jones
& Bartlett
LLC York:
9. Dewey,
J. Art asLearning,
Experience (New
connection
among ideas and things. This
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Capricorn Books, 1958).
clarifies the effect of each new thing known
on other things known and the discovery 10. Orem, D. E. Nursing: Concepts of
Practice (New York: McGraw-Hill Book
of new patterns by which each connection
Co., 1971).
modifies the whole.
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Learning, L
11. Lee, V. “Empathy” in Rader,
M., ed.
A
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Modern Book of Esthetics,
3rdFOR
ed. (New
York: Holt, Rinehart and Winston,
References
1960).
1. Carper, B. A. “Fundamental Patterns of 12. Lippo, T. “Empathy, Inner Imitation
in Nursing.”
PhDLLC
dissertation,
and Sense-Feeling”
Rader, M.,
ed. A
© Jones &Knowing
Bartlett
Learning,
© Jones &inBartlett
Learning,
LLC
College,
Columbia University,
Modern
BookFOR
of Esthetics,
ed.DISTRIBUTION
(New
NOT FORTeachers
SALE OR
DISTRIBUTION
NOT
SALE3rd
OR
1975.
York: Holt, Rinehart and Winston,
2. Kuhn, T. The Structure of Scientific
1960).
Revolutions (Chicago: University of 13. Mitchell, P. H. Concepts Basic to
Chicago Press, 1962).
(New York:
McGraw-Hill
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LLC
© JonesNursing
& Bartlett
Learning,
LLC Book
3. Northrop, F. S. C. The Logic of the
Co., 1973).
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Sciences and the Humanities (New 14. Buber, M. I and Thou. Translated by
York: The World Publishing Co., 1959).
Walter Kaufman (New York: Charles
4. Nagel, E. The Structure of Science (New
Scribner and Sons, 1970).
York: Harcourt, Brace and World, Inc., 15. Maslow, A. H. “Self-Actualizing People:
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, L
1961).
A Study of Psychological Health” in
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5. Weitz, M. “The Role of Theory in
Moustakas, C. E., ed. The Self (New
Aesthetics” in Rader, M., ed. A Modern
York: Harper and Row, 1956).
Book of Esthetics, 3rd ed. (New York: 16. Polanyi, M. Personal Knowledge (New
Holt, Rinehart and Winston, 1960).
York: Harper and Row, 1964).
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References
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33
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Part I.” Nurs Res 17 (September–
17. McKay, R. “Theories, Models and
NOT FOR SALE OR DISTRIBU
NOT
FOR
SALE
OR
DISTRIBUTION
October, 1968).
Systems for Nursing.” Nurs Res 18:5
20. Slote, M. A. “The Theory of Important
(September–October, 1969).
Criteria.” J Philosophy 63 (April 14,
18. Berthold, J. S. “Symposium on Theory
1966).
Development in Nursing: Prologue.”
© Jones &
Bartlett
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LLC
© Jones
& Bartlett
Learning, LLC
21. Greene,
M. Teacher
as Stronger
Nurs Res 17:3 (May–June, 1968).
NOT FOR
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OR
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NOT
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(Belmont,
CA:
Wadsworth
Publishing
19. Dickoff,
James,
P., and Wiedenbach,
Co., Inc., 1973).
E. “Theory in a Practice Discipline:
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