Carper's Ways of Knowing

Carper identified four ways of knowing that can be used as a guide to provide holistic care. These ways of knowing are Empirical, Personal knowledge, Ethical, and Aesthetic. They can be used to gain a clearer, more complete picture of a patient's care, ties into the nursing process and promotes learning by reflection.

Empirical knowing is knowledge based on scientific evidence, factual and objective descriptions. I recall an example of using this way of knowing when I recently had a patient admitted to the Tele Unit with a diagnosis of chest pain with chest pain standing orders on the chart. When I go into the patient's room to assess her she is audibly wheezing, has crackles in the lung bases, a persistent cough, and is short of breath with conversation. She has a history of CHF and COPD and intermittently has used home O2. She states that she's had these symptoms the last 2 days and has midsternal chest pain (from coughing) that feels like a pulled muscle yet none of these symptoms were addressed by the ER or admitting doctor. I immediately called the admitting physician to give him a status update and received more appropriate orders for a COPD exacerbation like nebs, solumedrol, iv lasix, and supplemental O2. Using the Empirical way of knowing helped the doctor gain a clearer picture of the patient and helped the patient get the care she needed.

Ethical knowing is knowledge used in moment-to-moment judgments on what is good, right and responsible when there is no black and white answer. It involves having to make choices between opposing interventions or priorities based on information and debate. For example, we had a patient dying of metastatic cancer that the family had eventually made Hospice. During his stay there his wife was very involved in his care but made many demands, some that went against nursing protocol. He was in considerable pain, even with the use of a Morphine PCA and his wife refused to have him turned or moved. The benefits and rationales of frequent turning and repositioning him were discussed at length with her but she continued to refuse. He eventually developed skin breakdown and decubitus ulcers which we explained to her are very painful as well. With the help of our manager, the attending doctor and nursing staff we came up with a plan with the family regarding his care and the plan was posted in his room so expectations were clear. While there is clear evidence that turning patients every 2 hours prevents skin break down and we have a moral/ethical obligation to the patient to be his advocate of what we know is good nursing care but that intervention competed with the family's wishes and views of wanting their loved one comfortable and pain free. Working with the family brought up many end of life issues that ensued much debate on our unit as all of us working with that patient wanted a good outcome for him.

Carper's third way of knowing is Personal Knowledge that comes from lived life experiences that draws