Nursing

1 3 4 FUND,, '. t I I

' 1 tific par: I

I 9 Structure

I Fundamental Pattc of Knowing ample clude [S] O: in Nursing k mentatia I models f

I NOTICE THIS MATERIAL 11 tradition! MAY BE PROTECTED BY

I COPYRIGHT LAW t argued tl- BARBARA A. CARPER, RN, EdD

(TITLE 17 U.S. CODE) seem to I :I providing 1 count for

It is the general conception of any field of in- nursing; and (4) ethics, the component of mately p quiry that ultimately determines the kind of moral knowledge in nursing. control oj

I I

knowledge the field aims to develop as well as determin, the manner in which that knowledge is to be Empirics: The Science / lidity of s organized, tested, and applied. The body of

of Nursing I I text of re1 knowledge that serves as the rationale for

nursing practice has patterns, forms, and The term nursing science was rarely used in the New Per structure that serve as horizons of expecta- literature until the !ate 1950s. However, since ' What see I tions and exemplify iharacteristic ways of that time there has been an increasing empha- at least a

i thinking about phenomena. Understanding sis, one might even say a sense of urgency, nursing r these patterns is essential for the teaching and regarding the development of a body of em- 1 conceptui l 1 I!

learning of nursing. Such an understanding pirical knowledge specific to nursing. There I does not extend the range of knowledge, but seems to be general agreement that there is a

1 present n familiar I:

rather involves critical attention to the ques- critical need for knowledge about the empiri- relation I tion of what it means to know and what kinds cal world, knowledge that is systematically or- they can of knowledge are held to be of most value in ganized into general laws and theories for the

I as discove the discipline of nursing. purpose of describing, explaining, and predict- tation of I ing phenomena of special concern to the disci- t disease i s , pline of nursing. Most theory development .!I be thougk

1 IDENTIFYING PATTERNS and research efforts are primarily engaged in which cha I OF KNOWING seeking and generating explanations which , varies accc

are systematic and controllable by factual evi- a static Four fundamental patterns of knowing have dence and ~ h i c h can be used in the organiza- change in been identified from an analysis of the con- tion and classification of knowledge. j tions that 1 ceptual and syntactical structure of nursing The pattern of knowing which is generally i unintelligi

I knowledge.' The four patterns are distin- designated as "nursing science" does not , The di guished according to logical type of meaning presently exhibit the Same degree of highly in- , ceptualize and designated as (1) empirics, the science of tegrated abstract and systematic explanations ranges a101 nursing; (2) esthetics, the art of nursing; ( 3 ) characteristic of the more mature sciences, al- the component of a personal knowledge in though nursing literature reflects this as an I I ?e,"iyo~~e

ideal form. Clearly there are a number of co- i a human existing, and in a few instances competing, and exten:

Source Carper, B. A. (1978) Fundamental patterns of knowing in nurang. ANS, I ( 1 ) . 13-24. Reprinted w t h pemusslon from and structures-none of which has has sough] copyright o 1978 Aspen Publ~shers, Inc achieved the status of what Kuhn calls a s ~ i e n - . both physic

i 22 i 1 1 -

used in the never, since jing empha- of urgency, )ody of em- :sing. There at there is a the empiri-

natically or- ories for the and predict- to the disci- evelopment engaged in

tions which factual evi-

ne organiza- ge. I is generally

does not of highly in- :xplanations sciences, al- j this as an ~mber of co-

competing, which has

calls a scien-

tific paradigm. That is, no single conceptua structure is as yet generally accepted as an ex- ample of actual scientific practice "which in- clude[~] law, theory, application, and instru- mentation together . . . [and] . . . provide[sl models from which spring particular coheren traditions of scientific r e s e a r ~ h . " ~ ( ~ ' ~ ) It could bl argued that some of these conceptual structures seem to have greater potential than others for providing explanations that systematically ac- count for observed phenomena and may ulti- mately permit more accurate prediction an+ control of them. However, this is a matter to bl determined by research designed to test the va lidity of such explanatory concepts in the con- text of relevant empirical reality.

re as cues by which one can infer the range or normal variations of health. It has also at- tempted to identify and categorize significant etiological factors which serve to promote or inhibit changes in health status.

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 sucl they can and should be legitimately countec as discoveries in the discipline. The represen tation 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 which changes over a given period of time and varies according to circumstances rather than a static eitherlor entity. The conceptual change in turn makes it possible to raise ques- tions 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 ma.

h exp d - con

, nec y me1

*rent Stages lne science of nursing at present exhibits aspects of both the "natural history stage of in- quiry" and the "stage of deductively formu- lated theory." The task of the natural history c+nqe is primarily the description and classifica-

1 of phenomena which are, generally speak- ascertainable by direct observation and in-

~ p e c t i o n . ~ But current nursing literature clearly reflects a shift from this descriptive and classifi- cation form to increasingly theoretical analysis which is directed toward seeking, or inventing, explanations to account for observed and clas- sified empirical facts. This shift is reflected in the change from a largely observational vocab- ulary to a new, more theoretical vocabulary whose terms have a distinct meaning and defi- nition only in the context of the corresponding

lanatory theory. Explanations in the several open-system ceptual models tend to take the form com-

monly labeled functional or tele~logical.~ For ex- ample, 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 explana- tion. Adaptation is seen as crucial in the process of responding to environmental de- mands (usually classified as stressors), and en- ables 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 explana- tion in that certain events, the developmental tasks, are believed to be causally relevant or

essary conditions for the normal develop- nt of an individual.

PART ONE: THE NURSING DISCIPLINE AND DEVELOPMENT OF KNOWLEDGE 1 FUND! Thus the first fundamental pattern of

knowing in nursing is empirical, factual, de- scriptive, and ultimately aimed at developing abstract and theoretical explanations. It is ex- emplary, discursively formulated, and publicly verifiable.

Esthetics: The Art of Nursing Few, if indeed any, familiar with the profes- sional literature would deny that primary em- phasis is placed on the development of the science of nursing. One is almost led to be- lieve that the only valid and reliable knowl- edge is that which is empirical, factual, ob- jectively descriptive, and generalizable. There seems to be a self-conscious reluctance to ex- tend the term knowledge to include those as- pects 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, a n art. Not much effort is made to elaborate or to make explicit this esthetic pattern of knowing in nursing-other than to vaguely associate the "an" with the general category of manual andlor technical skills involved in nursing practice.

Perhaps this reluctance to acknowledge the esthetic component as a fundamental pat- tern of knowing in nursing originates in the vigorous efforts made in the not-so-distant past to exorcise the image of the apprentice- type educational system. Within the appren- tice system, the art of nursing was closely as- sociated with a n imitative learning style and the acquisition of knowledge by accumulation of unrationalized experiences. Another likely source of reluctance is that the definition of the term art has been excessively and inappro- priately restricted.

Weitz suggests that art is too complex and variable to be reduced to a single defini- t i ~ n . ~ To conceive the task of esthetic theory as definition, h e says, is logically doomed to

failure in that what is called art has n o com- mon properties--only recognizable similari- ties. This fluid and open approach to the u n - derstanding 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 process of discovery in the empirical pattern of knowing.

Esthetics versus Scientific Meaning Despite 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," according to Rader, "is about as weii established as any fact in the whole field of esthetic^."^(^^^^' An es- thetic experience involves the creation andlor appreciation of a singular, particular, subjec- tive expression of imagined possibilities' or equivalent realities which "resists projection into the discursive form of language."' Knowl- edge gained by empirical description is discur- sively formulated and publicly verifable. The knowledge gained by subjective acquaintance, the direct feeling of experience, defines discur- sive formulation. Although an esthetic expres- sion required abstraction, it remains specific and unique rather than exemplary and leads us to acknowledge that "knowledge-genuine knowledge, understanding-is considerably wider than our

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 de- mands of his [sic] s i t ~ a t i o n . ~ But the action taken, to have a n esthetic quality, requires the active transformation of the immediate ob- ject-the patient's behavior-into a direct, nonmediated perception of what is significant in it-that is, what need is actually being ex-

press' need actiol

T bach differ t i ~ n . ~ the I: wher to S( scher goes activc tered for tl perce resul- gives

C " e x p ~ creati nursi The ; devel modc are Dewc actioi mear perie signe resul- inder dent the c total that c care fragn

Esth

Empi in or ings-

art has no com- gnizable similari- proach to the un- of the concept of

makes possible ,a litions, situations, :hat may properly ing the creative empirical pattern

the concept of art, istinguished from mportant aspects. expressive rather iptive," according :stablished as any i e t i ~ s . " ~ ( ~ ~ " ' ) An es- Le creation and/or )articular, subjec- d possibilities or 'resists projection nguage.Ip7 Knowl- icription is discur- cly verifable. The ive acquaintance, ce, defines discur- n esthetic expres- : remains specific mplary and leads wledge-genuine -is considerably m23)

jrt of nursing is :ion taken to pro- ?quires to restore :ope with the de- .' But the action ality, requires the e immediate ob- r-into a direct, vhat is significant ~ctually being ex-

pressed by the behavior. This perception of the need expressed is not only responsible for the action taken by the nurse but reflected i~

The esthetic process described by Wic bach resembles what Dewey refers to a= ULC difference between recognition and percep- t i ~ n . ~ According to Dewey, recognition 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 recognition in that it includ active gathering together of details and tered particulars into a n experienced t for the purpose of seeing what is there. It is perception rather than mere recognition that results in a unity of ends and means which 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 designing and providing nursing that is effective and ~atisfying."'~'P'~~) 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 a p p r ~ p r i a t e . " ' ~ ' ~ ~ ~ ' This again invokes Dewey's sense of a perceived unity between a n action taken and its result-a perception of the means of the end as an organic whole.9 The ex- perience of helping must be perceived and de- signed as a n integral component of its desired result rather than conceived separately as an independent action imposed on a n indepen- dent 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 minimize the fragmentation of means and ends?

P Esthetic Pattern of Knowing

1 it. eden- .r +La

les a n scat-

vhole

1 Empathy-that is, the capacity for participating in or vicariously experiencing another's feel-

j ings-is an important mode in the esthetic pat- +

tern of knowing. One gains knowledge of an- other person's singular, particular, felt experi- ence through empathic a~quaintance.".'~ Em- pathy is controlled or moderated by psychic distance or detachment 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 ef- fective and satisfying. At the same time, in- creased awareness of the variety 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 t ~ g e t h e r . " ~ ( ~ ' ~ ) The design, if it is to be esthetic, must be controlled by the per- ception of the balance, rhythm, proportion, 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 routine or of ~ a p r i c e . ~

The esthetic pattern of knowing in nurs- ing involves the perception of abstracted par- ticulars 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 essen- tial to understanding the meaning of health in terms of individual well-being. Nursing consid- ered as an interpersonal process involves inter- actions, relationships, and transactions between the nurse and the patient-client. Mitchell points out that "there is growing evidence that the quality of interpersonal contacts has an influ- ence on a person's becoming ill, coping with ill- ness and becoming i ell."'^(^^^^) Certainly the phrase "therapeutic use of self" which has be- come 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 confronting that human being as a person. This "I-Thou" en- counter is unmediated by conceptual cate- gories or particulars abstracted from complex organic wholes.14 The relation is one of reci- procity, a state of being that cannot be de- scribed 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, i.e., categories or classifications, 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 stat of lines-one must pull and tear to tu unity into a multiplicity-so it is with human being to whom I say You. . . . have to do this again and again; but ir mediately he is n o longer YOU.'^'^^^'

the 1 7

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(~'7)

The nurse in the therapeutic use of self rejects approaching the patient-client as an ob- ject and strives instead to actualize an authen- tic 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 accep- tance of others in their freedom to create themselves and the recognition that each per- son is not a fixed entity, but constantly en- gaged in the process of becoming. How then should the nurse reconcile this with the social and/or professional responsibility to control and manipulate the environmental variables and even the behavior 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 ac- cepted 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 re- lation apart from the category of patient, even when categorizing for the purpose,of treatment is essential to the process of nursing?

Assumptions regarding human nature, McKay observes, "range from the existentialist to the cybernetic, from the idea of an informa- tion processing machine to one of a many jplendored being."17(P399) M any of these as- jumptions incorporate in one form or another the notion that there is, for all individuals, a characteristic state which they, by virtue of membership in the species, must strive to as- sume or achieve. Empirical descriptions and

clas hur PSY enc

to t req. els gen hav mol eve the "sel atio kno ized is CI pro] son; mer the

Eth

Tea( con; pers corn choi mor witk pro1 situi the to p1 codt dicti ical prin cept hum be a spor ing,

:eneralized nor x of concepts, : e ~ t y p e s . ' ~ This to accept ambi- 3ncy of oneself tment involved 3t Polanyi calls in the act of

utic use of self -client as an ob- ~lize an authen- In two persons. ; an integrated, vement toward In potential. An uires the accep- dom to create I that eachper- constantly en- ling. How then with the social ility to control lental variables )erson who is a restore a steady led to be free to outside of ac-

ffect the action of self by the nurse make in n authentic re- )f patient, even ae,of treatment .sing? uman nature, l e existentialist of a n informa- ne of a many y of these as- >rm or another I individuals, a I, by virtue of 1st strive to as- :scriptions and

classifications reflect the assumption that being human allows for prediction of basic biological, psychological, and social behaviors that will be encountered in any given individual.

Certainly empirical knowledge is essential to the purposes of nursing. But nursing also requires that we be alert to the fact that mod- els of human nature and their abstract and generalized categories refer to and describe be- haviors and traits that groups have in com- mon. However, none of these categories can ever encompass or express the uniqueness of the individual encountered as a person, as a "self." These and many other similar consider- ations are involved in the realm of personal knowledge, which can be broadly character- ized as subjective, concrete, and existential. It is concerned with the kind of knowing that promotes wholeness and integrity in the per- sonal encounter, the achievement of engage- ment rather than detachment; and it denies the manipulative, impersonal orientation.

Ethics: The Moral Component

Teachers and individual practitioners are be- coming increasingly sensitive to the difficult personal choices that must be made within the complex context of modern health care. These choices raise fundamental questions 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 n o help or seem to result in contra- diction. The moral code which guides the eth- ical conduct of nurses is based on the primary principle of obligation embodied in the con- cepts of service to people and respect for human life. The discipline of nursing is held to be a valuable and essential social service re- sponsible for conserving life, alleviating suffer- ing, and promoting health. But appeal to the

ethical "rule book" fails to provide answers in terms of difficult individual moral choices, which must be made in the teaching and prac- tice of nursing.

The fundamental pattern of knowing identified here as the ethical component of nursing is focused on matters of obligation or what ought to be done. Knowledge of moral- ity goes beyond simply knowing the norms or ethical codes of the discipline. It includes all voluntary actions that are deliberate and sub- ject to the judgment of right and wrong-in- cluding judgments of moral value in relation to motives, intentions, and traits of character. Nursing is deliberate action, or a series of ac- tions, planned and implemented to accom- plish defined goals. Both goals and actions in- volve choices made, in part, on the basis of norrrlative j~lrlzments,. both particular and general. On occasion, the principles and norms by which such choices are made may be in conflict.

According to Berthold, "goals are, of course, value judgments not amenable to sci- entific inquiry and ~ a l i d a t i o n . " ' ~ ( p ' ~ ~ ) Dickoff, James, and Wiedenbach also call attention to the need to be aware that the specification of goals serves as "a norm or standard by which to evaluate activity. . . [and] . . . entails taking them as values-that is, signifies conceiving these goal contents as situations worthy to be brought a b ~ u t . " ' ~ ( ~ ~ ~ ~ )

For example, a common goal of nursing care in relation to the maintenance or restora- tion of health is to assist patients to achieve a state in which they are independent. Much of the current practice reflects an attitude of value attached to the goal of independence, and indicates nursing actions to assist patients in assuming full responsibility for themselves at the earliest possible moment or to enable them to retain responsibility to the last possi- ble moment. However, valuing independence and attempting to maintain it may be at the expense of the patient's learning how to live

28 PART ONE: THE NURSING DISCIPLINE AND DEVELOPMENT OF KNOWLEDGE

with physical or social dependence when nec- essary-for example, in instances when prog- nosis indicates that independence cannot be regained.

Differences in normative judgments may have more to. do with disagreements as to what constitutes a "healthy" state of being than lack of empirical evidence or ambiguity in the application of the term. Slote suggests that the persistence of disputes, or lack of uni- formity in the application of cluster terms, such as health, is due to "the difficulty of deci- sively resolving certain sorts of value ques- tions about what is and is not important." This leads him to conclude "that value judgment is far more involved in the making of what are commonly thought to be factual statements

- than has been imagined."20'p220) - -- The ethical'pattern of knowing in nursing

requires an understanding of different philo- sophical positions regarding what is good, what ought to be desired, what is right; of dif- ferent ethical frameworks devised for dealing with the complexities of moral judgments; and of various orientations to the notion of obliga- tion. Moral choices to be made must then be considered in terms of specific actions to be taken in specific, concrete situations. The ex- amination of the standards, codes, and values by which we decide what is morally right should result in a greater awareness of what is involved in making moral choices and being responsible for the choices made. The knowl- edge of ethical codes will not provide answers to the moral questions involved in nursing, nor will it eliminate the necessity for having to make moral choices. But it can be hoped that:

The more sensitive teachers and practi- tioners are to the demands of the process of justification, the more explicit they are about the norms that govern their ac- tions, the more personally engaged they are in assessing surrounding circum- stances and potential consequences, the

more "ethical" they will be; and we can- not ask much more.21(p221)

USING PATTERNS OF KNOWING

A philosophical discussion of patterns of knowing may appear to some as a somewhat idle, if not arbitrary and artificial, undertak- ing having little or no connection with the practical concerns and difficulties encoun- tered in the day-to-day doing and teaching of nursing. But it represents a personal convic- tion that there is a need to examine the kinds of knowing that provide the discipline with its particular perspectives and significance. Understanding four fundamental patterns of knowing makes possible an increase:! 2ws:e- ness of the complexity and diversity of nurs- ing knowledge.

Each pattern may be conceived as neces- sary for achieving mastery in the discipline, but none of them alone should be considered sufficient. Neither are they mutually exclu- sive. The teaching and learning of one pattern do not require the rejection or neglect of any of the others. Caring for another requires the achievements of nursing science, that is, the knowledge of empirical facts systematically or- ganized into theoretical explanations regard- ing the phenomena of health and illness. But creative imagination also plays its part in the syntax of discovery in science, as well as in de- veloping the ability to imagine the conse- quences of alternative moral choices.

Personal knowledge is essential for ethical choices in that moral action presupposes per- sonal maturity and freedom. If the goals of nursing are to be more than conformance to unexamined norms, if the "ought" is not to be determined simply on the basis of what is pos- sible, then the obligation to care for another human being involves becoming a certain kind of person-and not merely doing certain

kinds < to be I capacil tive ex projecf lives bc

Nu know11 in illne humar ing of 1 the cay situatic ments. and in1 knowir cordinj circum data it each pi and WE

Thl of nu1 knowil sions c matter referen the reF i n q u i r ~ edge g~ validity of kno. comple questio edge is solutio: and un yet uns methoc structu terns o shape ( require and cox clarifiet

of patterns of : as a somewhat icial, undertak- x t i o n with the :ulties encoun- and teaching of lersonal convic- 3mine the kinds discipline with

~d significance. ntal patterns of wreased aware- versity of nurs-

zeived as neces- I the discipline, d be considered nutually exclu- g of one pattern r neglect of any '" ler requires the Ice, that is, the lstematically or- nations regard- and illness. But 's its part in the as well as in de- 1 ine the conse- t hoices. :ntial for ethical resupposes per- .. If the goals of '

:onformance to ' ght" is not to be i of what is pos- are for another i ning a certain I ly doing certain I

kinds of things. If the design of nursing care is to be more than habitual or mechanical, the capacity to perceive and interpret the subjec- tive experiences of others and to imaginatively project the effects of nursing actions on their lives becomes a necessary skill.

Nursing thus depends on the scientific knowledge of human behavior in health and in illness, the esthetic perception of significant human experiences, a personal understand- ing of the unique individuality of the self, and the capacity to make choices within concrete situations involving particular moral judg- ments. Each of these separate but interrelated and interdependent fundamental patterns of knowing should be taught and understood ac- cording to its distinctive logic, the restricted circumstances in which it is valid, the kinds of data it subsumes, and the methods by which each particular kind of truth is distinguished and warranted.

The major significances to the discipline of nursing in distinguishing patterns of knowing are summarized as (1) the conclu- sions of the discipline conceived as subject matter cannot be taught or learned without reference to the structure of the discipline- the representative concepts and methods of inquiry that determine the kind of knowl- edge gained and limit its meaning, scope, and validity; ( 2 ) each of the fundamental patterns of knowing represents a necessary but not complete approach to the problems and questions in the discipline; and ( 3 ) all knowl- edge is subject to change and revision. Every solution of an existing problem raises new and unsolved questions. These new and as yet unsolved problems require, at times, new methods of inquiry and different conceptual structures; they change the shape and pat- terns of knowing. With each change in the shape of knowledge, teaching and learning require looking for different points of contact and connection among ideas and things. This clarifies the effect of each new thing known

on other things known and the discovery of new patterns by which each connection modifies the whole.

REFERENCES

1. Carper, B. A. "Fundamental Patterns of Know- ing in Nursing." PhD dissertation, Teachers Col- lege, Columbia University, 197 5.

2. Kuhn, T. The Structure of Scientific Revolutions (Chicago: University of Chicago Press 1962).

3. Northrop, F. S. C. The Logic of the Sciences and the Humanities (New York: The World Publishing Co. 1959).

4. Nagel, E. The Structure of Science (New York: Harcourt, Brace and World, Inc. 196 1 \.

5. Weitz, M. "The Role of he or^ in ~ e s t h e t i c s " in Rader, M., ed. A Modem Book of Esthetics 3rd ed. (New York: Holt, Rinehart and Winston

- 1960). 6. Rader, M. "Introduction: The Meaning of Art"

in Rader, M., ed. A Modem Book of Esthetics 3rd ed. (New York: Holt, Rinehart and Winston 1960).

7. Langer, S. K. Problems ofArt (New York: Charles Scribner and Sons 1957).

8. Wiedenbach, E. Clinical Nursing: A Helping Art (New York: Springer Publishing Co., Inc. 1964).

9. Dewey, J. Art as Experience (New York: Capri- corn Books 1958).

10. Orem, D. E. Nursing: Concepts of Practice (New York: McGraw-Hill Book Co. 1971).

11. Lee, V. "Empathy" in Rader, M., ed. A Modem Book of Esthetics, 3rd ed. (New York: Holt, Rine- hart and Winston 1960).

12. Lippo. T. "Empathy, Inner Imitation and Sense- Feeling" in Rader, M., ed. A Modem Book of Es- thetics 3rd ed. (New York: Holt, Rinehart and Winston 1960.)

13. Mitchell, P. H. Concepts Basic to Nursing (New York: McGraw-Hill Book Co. 1973).

14. Buber, M. I and Thou. Translated by Walter Kaufman (New York: Charles Scribner and Sons 1970).

15. Maslow, A. H. "Self-Actualizing People: A Study of Psychological Health" in Moustakas, C. E., ed. The Self (New York: Harper and Row 1956).

16. Polanyi, M. Personal Knowledge (New York: Harper and Row 1964).

PART Om: THE NURSING DISCIPLINE AND DEVELOPMENT OF KNOWLEDGE

McKay, R. "Theories, Models and Systems for 20. Slote, M. A. 'The Theory of Important Crite- Nursing." Nurs Res 18:5 (September-Octobc ria." J Philosophy 63 (April 14 1966). 1969). 1. Greene, M. Teacher as Stronger (Belmont, Calif.: - Berthold, J. S. 'Symposium on Theory Deve Wadsworth Publishing Co., Inc. 1973). opment in Nursing: Prologue." Nurs Res 17: (May-June 1968). Dickoff, J., James P., and Wiedenbach, E. 'Thc ory in a Practice Discipline: Part I." N u n Res 1 (September-October 1968).

A discil organiz of an ac cipline knowle

L human ence a1

i pline, r questio adding practice

I Thc exempl , scribes, and thc pline a1 ers.) Tl

., general Source: iv of nursing

1 sion from,