What is Unknowing? It’s a way of being open to what you may not know.What is Unknowing? It’s a way of being open to what you may not know.
LESSON:
Nursing’s Ways of Knowing and Theories of Knowledge
Since the dawn of modern nursing in Florence Nightingale’s day, nurses have sought to understand the art and science of nursing. A good place to start in our quest to understand nursing is to begin with a concept called ways of knowing (Alligood, 2014). These phenomena are not unique to nursing; all disciplines and all beings are informed by ways of knowing.
Ways of knowing contribute to our mastery of nursing practice; while theories of knowledge (Epistomology, Ontology and Axiology), hold philosophical tenants about what knowledge is and how our beliefs about it direct our scientific inquiries (research). Nurse theorist, Carper (1978) identified four fundamental patterns of knowing in nursing. She described these patterns (or ways of knowing) as (a) empirics, (b) aesthetics, (c) ethics, and (d) personal knowing. A pattern of knowing is a notion similar to a way of knowing, but it’s personal, inside a being or patterns among groups of beings (such as nurses).
Ways of knowing in nursing incorporate knowledge that is systematically organized into general laws and theories in order to describe, explain, and predict phenomena of special concern to nursing. Since Carper developed her model, other nurse theorists, Patricia Munhall and Christopher Johns, have added two more important ways of knowing; Unknowing and Socio-Political Knowing, respectively (Heath, 1998). It is most important to consider how you as a nurse have developed mastery in your practice within the context of these six Ways of Knowing.
What is Unknowing? It’s a way of being open to what you may not know. This is used by nurses all of the time when they ask patients and families questions and listen with an open mind so as to find out what’s going on for them. An example of being ‘unknowing’ would be to ask a patient what’s most important to them right now; and then of course to listen with the intent of helping them get what they need.
Socio/Political Knowing is about issues of power, whose voice is heard, whose voice is silent and this helps nurses understand when and how they might act in relation to others in the landscape of health care.
Beyond ways of knowing among beings and groups in disciplines, there are theories of knowledge, a philosophical examination of what knowledge is and how it comes about. The most commonly recognized theories of knowledge are categorized in three areas: epistemology, ontology, and axiology. Some would argue that nursing knowledge emerges at the intersection of these theories of knowledge, as illustrated in this simple Venn diagram.
Theories of Knowledge
• Epistemology is the study of empirical knowledge, typically resulting from scientific inquiry. It is organized according to what we believe to be true (or factual), and when applied to nursing, best connects with the science of nursing. Epistemology encompasses empirical knowledge and also teleological knowledge, the process of knowledge (interpolation and extrapolation), and additional contributions to knowledge.
• Ontology is the study of reality and being. Knowledge in ontology unfolds according to what we experience and take ourselves to be. Ontological knowledge focuses on application and is often attributed to the art of nursing or aesthetics. An ontological question commonly asks, “What is it like to ‘be’ in (some phenomenon, such as pain or caring for a chronically ill person or anything we experience as beings?” A researcher whose philosophy of knowledge bends toward ontology is interested in beings experience in the world.
• Axiology is the philosophical study of value. Studies within the philosophy of axiology examine ethical dilemmas and questions.
In nursing practice, nurses search for knowledge within the various philosophies of knowledge. For example, empirical information is important to know facts, numbers, trends and processes. Nurses also seek knowledge of ontology when reading qualitative studies and inquiring about a client’s experience and personal meaning. Nurses also inquire within the philosophy of axiology to address ethical dilemmas. Carper, however, described another pattern called personal knowing. As nurses, we know that epistemology benefits from additional contributions to knowledge, such as logical reasoning (inductive and deductive), reasoning by analogy, the influence of chance, and imagination in science, intuition, and discussion as a stimulus. These additional sources of knowledge contribute to personal knowledge.
In future courses, you will learn more about the scientific method, an important element of inquiry. As Doctors of Nursing Practice, you will examine research studies to determine their worth in serving as foundational evidence for practice change. While there are many elements to consider in critiquing knowledge generated from research, for now it is good to recognize the basic philosophical underpinnings of knowledge development. Take this information in hand and consider it as you build your discussion and interactions in the threads this week.
See if you can correctly place the Theories of Knowledge in the exercise below.
Theories of Knowledge
Ways of KnowingTheories of Knowledge
Drag and drop the terms related to different Theories of Knowledge.
Transcript
Framing the Practice Question
The PICOT approach is a method for framing practice questions in nursing. The problem/etiology statement that you wrote in week one sets the stage for interventional designs. In other words, from your distinct problem/etiology statment you will develop a PICOT question that lends itself to your search for evidence to support the claim that the problem exists and that the intervention can possibly be an effective address to an improvement in the problem situation.
The PICOT statement serves to formulate a clear practice question. According to Melnyk and Fineout-Overholt (2011), the practice question should include (a) the population to which you will address the intervention; (b) the intervention that addresses the etiology; (c) the comparison (what is happening now; (d) the expected outcome having tried the intervention; and (e) the time frame in which you will conduct this project.
As a side note, while the PICOT lends itself to quantitative approach to your project, the PICoT lends itself to a qualitative approach to an EB project such that the elements become (a) the population of interest; (b) the phenomena of interest; (c) the context of interest; and (d) the time frame. As a student in this program, focus your attention and development on the PICOT approach.
The PICOT format can be used to answer different types of practice questions (e.g., intervention, diagnosis or diagnostic tests, prognosis or prediction, etiology, and meaning). Many of you will be formulating intervention type questions for your DNP projects. For example, let’s say that you have identified that there is a high incidence of ventilator-associated pneumonia in adult patients in the intensive care unit in your hospital and you want to know if implementing an evidence-based practice intervention from the literature will lead to a decreased incidence rate.
If you were to set up a PICOT using this practice situation, your question might then be narratively stated as: “For mechanically ventilated adult patients in the intensive care unit (P), does the use of the Institute for Healthcare Improvement (IHI) ventilator-associated pneumonia (VAP) bundle (I) compared to standard care (C) lead to a decreased VAP rate (O) within 2 months (T)?”
Begin with week 1 problem statement (problem and etiology) and then write the letters PICOT down the vertical side of a page and fill in your ideas for the Population, Intervention, Comparison, Outcome and Timeline. Using the example above, your page would look this way:
Starting with your problem statement you had noted that There are high incidence of VAP (problem)/ related to, inconsistent practices of elevating head of bed, over-sedation, lack of standardized prevention practices (etiology).
P = Ventilator dependent ICU patients on x unit in x organization
I = IHI VAP prevention bundle***
C = Standard care without this prevention bundle
O = Reduced incident rate of VAP for ICU patients
***(NOTE that this intervention is directly aimed at the etiology as stated in our week 1 problem statement).
Summary
In summary, the scientific underpinnings for advanced nursing practice (Zaccagnini & White, 2017) provide a foundation for merging nursing theory, nursing research, and evidence-based practice. The expected outcomes of such scientific underpinnings for advanced nursing practice are then driven by a quest for quality improvement in healthcare (Nelson, Batalden, & Godfrey, 2007) that leads to healthcare value by design at the microsystem, mesosystem, and macrosytem levels (Nelson, Batalden, Godfrey, & Lazar, 2011).
QUESTIONS:
From the perspective of your practice change interest (clinical outcomes, safety and quality, leadership or health policy) consider the specific ways of knowing as they have played into your awareness of the need for practice change?
Further, consider how intuitive/personal or ‘unknowing’ knowing dimensions of practice integrate with broader social, cultural and theoretical dimension to create meaning and inform ideas for practice change.
Give two specific examples from your practice. For example, let’s say that your practice change interest is in the way treatment decisions are made in end-of-life care for elderly patients. Which ‘Ways of Knowing’ have played primarily in to your observations and insights about this problem?
Examples of integration with broader social and cultural dimensions in this scenario of treatment decisions in end-of-life care: how does your intuitive/personal knowing integrate with what patients and families say about their experiences? What do you know about the cost of care, access to care or quality of care relative to the issue?
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