How nursing students can be empowered byreflective practic

How nursing students can be empowered by
reflective practice
Dolphin, Sarah . Mental Health Practice (through 2013) ;
London Vol. 16, Iss. 9, (Jun 2013): 20-23.
ProQuest document link
FULL TEXT
Headnote
Reflection is not just another chore to complete on the way to
qualifying, says Sarah Dolphin. She provides a
detailed description of how this skill helped her to learn from
one particular incident during her training
Abstract
Reflective practice is seen as an important skill to develop
because it enables a nurse to become self-aware and
provide the best possible patient care.
This article describes how an incident during the administration
of an injection caused the author to examine

critically the events that occurred and their effect on patient and
practitioner, and to learn from them. It is argued
that reflecting on practice in this way enables nurses to develop
professionally and personally and, ultimately,
results in a higher standard of care.
Keywords
Reflective practice, self-awareness, communication, personal
development, nursing student
AT UNIVERSITY we are told that reflective practice is crucial
to being a good nurse. It allows the practitioner to
understand what occurred and to use the experience to improve
care (Jindal-Snape and Holmes 2009, Mann et al
2009). But in my experience many nursing students and
practitioners dismiss reflective practice as irrelevant,
perhaps because we are only required to think about it and do
not need to evaluate it further.
For my part, as this issue was assessed in a second-year module,
I considered it to be something simply to tick
offto pass the course. The critical incident I chose to reflect on
leftme feeling terrible. At the time of the incident I
wanted to bury my head in the sand and pretend that it had not
happened. If it had not been for someone pushing
me to write a reflective account I would never have realised that

the incident was not a disaster but a situation to
learn from.
Here, I examine the incident and reflect on it to try to illustrate
how useful the skill of reflection is.
Reflection does not simply mean thinking about a situation: it is
the systematic appraisal of events that occurred
and examination of their individual components to learn from
the experience and influence future practice. It
requires a high level of self-awareness and conscious efforts.
This effort can develop into reflexivity, which can
challenge beliefs and assumptions (Brechin 2000).
Ichheiser (1970) highlighted that 'the psychologically naïve,
unreflective person lives and acts under the silent
assumption that he perceives other people in a factual, objective
way'. Reflective practice is crucial to
acknowledge that objectivity is impossible without first
understanding that practitioners will have an effect on
patient care, whether directly or through others, via their body
language and other non-verbal and verbal
communication, and their thoughts and emotions.
The incident
I have chosen to use Gibbs's model of reflection (Gibbs 1988),
however I have adapted it by combining the

evaluation and analysis steps into a single section. The event I
reflect on was the administration of a depot
injection that took place in a patient's home. The injection was
not given as it should have been: the vial shattered
PDF GENERATED BY SEARCH.PROQUEST.COM Page 1 of 6
http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.p
roquest.com%2Fdocview%2F1370335479%3Faccountid%3D279
65
http://library.capella.edu/login? qurl=https%3A%2F%2Fsearch.p
roquest.com%2Fdocview%2F1370335479%3Faccountid%3D279
65
when I tried to open it and I cut myself. My mentor, who I will
call Alison, gave me first aid. I then failed to give the
injection at the next attempt and had to repeat the procedure to
give the prescribed dosage.
Description
There were three of us in the house at the time of the incident:
the patient, myself and Alison. The purpose of our
visit was to deliver a long-acting antipsychotic injection, which
I was going to administer under Alison's
supervision and with the patient's consent. We had explained
why the medication had been prescribed and had
asked the patient whether there had been any reactions to, or
problems since, the previous injection was given.

This was the second time I had given injection - my first was to
a different patient the previous day and the
procedure had gone smoothly. The only feedback was that I
should try to talk to the patient while giving the
injection because this would help her feel more at ease. It was
acknowledged that this would become easier as my
confidence grew.
On the second occasion, I carried out the injection using the Z-
track technique at the dorsogluteal site (Dougherty
and Lister 2011). When I met resistance from the muscle I
stopped depressing the plunger and withdrew the
needle, but Alison informed me that I had not administered the
entire dose. I replaced the needle with a new one to
reduce the risk of infection and gave the remainder of the dose
with no problem. I had discussed the re-
administration with the patient, apologised for having to re-
administer and obtained consent.
Feelings and thoughts
Throughout the process I was nervous. Despite having given one
injection already with no problems, I was still
inexperienced and did not have confidence in my ability to give
medication in that form. At each stage of the
process I had conflicting emotions, thoughts and feelings - for

example, pride at not having 'wimped' out, while also
being apprehensive about being able to continue. I thought I
might feel overwhelmed by the process, make a
mistake or have to hand over to Alison. The thought of being
overwhelmed was much stronger than the pride I was
feeling. It almost took over my focus on the intervention I was
carrying out, and other emotions and thoughts also
distracted me.
When the needle was withdrawn and Alison told me that the
patient had not received the full dose I could feel
myself getting flushed and hot. I did not want others to be
aware of my stress and embarrassment and think that I
was not competent to administer the injection. However, I found
Alison's presence reassuring in that she could
assist me should I need it, and she was helpful in guiding me
through the process. Alison gave me positive
feedback to boost my confidence and put me at ease. This
created a good feeling that I was acting and carrying
out the required actions in the appropriate way, and it helped
because she would not have given me such feedback
if she thought I was not capable.
Evaluation and analysis
When I was told that I had not administered the medication

fully I suddenly became aware of my position in
relation to the patient and Alison's proximity to me. I became
mindful that I was within their intimate space, which
made me feel uncomfortable. The patient was still and quiet,
which could be interpreted in different ways: they
were unaware of the situation and of how I was feeling; they
were concerned that I might need to administer again;
or they were not concerned and were waiting for me to inform
them of what was going on - which I did as I
progressed through the next steps.
At this point, my mind went blank. I froze even though I should
have been finding a plaster to put on the injection
site before continuing and was unable to speak. Then I heard
Alison move from the sofa, which was about five feet
behind me, and stand next to me. Although I felt reassured by
this, I was still anxious, and could feel my heartbeat
quicken.
Communication among professionals, or in this case a nursing
student and mentor, is essential to maintain good
patient care and safe practice; a lack of communication can lead
to problems in the patientprofessional
relationship (Shah 1993, Washer 2009).
Alison told me that I had not administered the full dose and I

responded by becoming physically rigid. I turned my
head to look at her with an expression of apprehension, anxiety
and fear. I felt my face flush red, my eyes widened
and I opened my mouth slightly to help take a deep breath as I
realised I had been holding my breath. Although I
perceived this reaction as a negative communication at the time,
I took solace in the notion that many emotions
are 'expressed best by non-verbal language' (Hosley and Molle-
Matthews 2006).
When Alison knelt beside me, she was square on to me so I
could see without having to turn my body that her
posture was open. She was leaning in towards me as she guided
me, making eye contact whenever it was
appropriate, and appeared to be relaxed and confident. Although
at the time I did not notice this, because I was
focused on the task in hand, I was reassured that she was close
by to help me through the next steps. Her
movement from the sofa was also a method of communication.
The message I received was that she was there for
me. I communicated my relief by looking at her and
acknowledging her presence.

She made gestures to indicate what I needed to do while talking
to me in a low, quiet tone that conveyed she was
calm. I could hear her clearly but the patient would not have
been able to do so. She talked me through what I
needed to do next, using unambiguous language - for example:
'Right, so what you need to do now is attach a new
needle to the syringe. Good. Next you need to...' This allowed
me to go through her instructions one step at a time.
Doing so prevented me from becoming more confused and
anxious, and forgetting what she had said and having
to ask her to repeat it. I acknowledged what she said by
paraphrasing, summarising, reflecting and clarifying
(Stickley and Stacey 2009). Although I did not recognise this at
the time, I was practising active listening skills.
After the patient had consented to me administering the
injection again and I carried out Alison's instructions, I
was upset that I needed her help in the first place. I felt like a
failure for not being able to administer the injection
when I had done so before without any problems. I was also
nervous about what else might go wrong, which added
to my anxiety. However, as I completed each step of her
instructions I noticed I was not feeling any particularly
strong emotions because I was concentrating so much on the
task.

I then became aware that the patient had not been spoken to for
a while. It seemed like minutes but had in fact
only been a few seconds. I broke the silence by telling them that
we were nearly done and Alison then turned to
look at me, nodded and gave me a smile. This reassured me that
I had done the right thing and I felt less tense.
As I finished the final step of putting the plaster on the
injection site, I felt a wave of relief, I wanted to show that I
was calm and that nothing remarkable had happened. However,
this could not have been reflected in my body
language because the patient informed me that I had not hurt
them and that I had done well. This revealed that I
was not as in control of my body language as I had thought and
that I needed to find a way of being more aware of
myself. I took comfort in Hosley and Molle-Matthews's
assertion (2006) that many emotions are 'expressed best by
non-verbal language'. But I was still embarrassed and upset.
During this experience, I had a certain degree of power over the
patient. I was aware of this to an extent, in that if
the patient refused to have the injection then this would be
reported, and if it continued it could result in them
being recalled to hospital. However, when the incident took
place, there was a noticeable shiftin power from me to
the patient. The patient could have insisted that I stop

administering the medication and that it was given by the
qualified nurse. The patient could also have refused to let me
return for any future visits. Alison had power over me
at this point, too, and I could feel myself submitting to this in
my body language, slouching slightly as she moved
towards me even though I had stiffened my muscles. At that
point she also had power over me in terms of holding
the knowledge about what steps I should take to continue with
the administration. I was also aware that I now felt
vulnerable, when before I had perceived the patient to be the
vulnerable one.
But as I continued with the drug administration, I felt
empowered. By being given instructions about what I should
be doing, I was able to take greater control (Norman and Ryrie
2009) of what was happening, and not simply give
up. I gained a greater understanding of why it is important to
empower patients; being empowered myself showed
me how much it can help increase confidence.
Success and failure
I believe the incident as a whole was a success and a failure. It
was a success because the medication was
administered as prescribed. On the other hand, breaking the
vial, withdrawing the needle too soon, the lack of

communication and my nervousness, were all negative aspects
of the process. On reflection, though, it did not go
as badly as I thought it had, and I am embarrassed about my
reactions to the events. The communication that
occurred during this incident was positive. It was effective in
that it conveyed to me what I needed to do next and
that the situation could be rectified through communication, co-
operation and collaboration between the three of
us. Although the main focus of the communication was between
two individuals, there were three of us involved,
and all of us were communicating in some way.
There were many aspects of the situation described that I
believe I could have carried out in a more positive way.
When I realised that I had not given the full dose, I should have
placed the syringe back onto the tray following
removal of the needle and communicated verbally with Alison
about what the next action should be. This would
have helped me to relax and I could have turned to face her.
This would also have shown that I was listening
intently. I would then have demonstrated this through my
communication with her. Although I believe I did this

during the incident, I could have done it more effectively if I
had been making eye contact.
I could also have been more assertive by asking Alison to move
closer to me when carrying out the injection. Her
physical presence would have reassured me. But when the
procedure was being undertaken, I was aware that she
was in the room and was happy for her to stay on the sofa as she
could observe well from there. This is because I
was feeling confident following the success of my previous
injection I had administered.
I should also have checked visually to see that all of the
medication had been administered, if I had done so the
incident that followed would not have taken place.
Paradoxically, I would then not have had the experience of
having to re-administer the medication and would not have
become aware of how much my body language
conveys my emotions and the importance of using active
listening skills to enhance communication among
practitioners.
Action plan
In future, if I think that the process of administering medication
is not being carried out perfectly, I will try to
remain calm. I will take a deep breath and speak to the nurse
who is supervising me. I must also practise trying to

maintain a professional demeanor and remain in control of my
body language. If I become injured and I am unsure
of how to act, I will ask a member of staffimmediately or as
soon after the event as is possible to receive any
necessary treatment or first aid. I will then complete any
relevant paperwork. Furthermore, I must ensure that I
acknowledge the patient who is being given the injection
because throughout the process described here, my
focus was on the task in hand and not on the patient.
Discussion
The reflection I undertook required me to identify the individual
components of this incident, explore my feelings
and my selfawareness surrounding those components, and
critically examine them to improve my practice. This
highlighted all aspects of the incident and helped me to develop
professionally. It also helped me develop my
personal way of carrying out some aspects of my practice, such
as administrating intramuscular injections while
adhering to best practice guidelines.
Since carrying out this reflection, I have administered many
injections successfully. Using reflective practice has
been beneficial because I have been able to tell my supervisor
whether I wanted him or her to move next to me or if

I needed help. This feeling of empowerment and the confidence
it gave me took me by surprise and made me want
to reflect thoroughly in the future.
Conclusion
Initially, I thought reflection was irrelevant, but through
experience I have learned that this is not the case.
Reflection allowed me to examine an incident and turn what I
had believed to be a negative experience into a more
positive one. It has had a positive effect on my self-awareness
and communication, and has strengthened my
practice. It has also given me pride in the skills I have
developed. Nursing students should regard reflection as a
valuable tool.
Sidebar
Alison made gestures to indicate what I needed to do while
talking to me in a low, quiet tone that conveyed that
she was calm
Online archive
For related information, visit our online archive of more than

7,000 articles and search using the keywords
Conflict of interest
None declared
References
References
Brechin A (2000) Introducing critical practice. In Brechin A,
Brown H, Eby M (Eds) Clinical Practice in Health and
Social Care. Sage, London.
Dougherty L, Lister S (2011) The Royal Marsden Hospital
Manual of Clinical Nursing Procedures. Student edition.
Wiley-Blackwell, Chichester.
Gibbs G (1988) Learning by Doing: A Guide to Teaching and
Learning Methods. Oxford Further Education Unit,
Oxford.
Hosley J, Molle-Matthews E (2006) A Practical Guide to
Therapeutic Communication for Health Professionals.
Saunders Elsevier, St Louis MI.
Ichheiser G (1970) Appearances and Realities:
Misunderstanding in Human Relations. Jossey-Bass, San
Francisco
CA.

Jindal-Snape D, Holmes E (2009) A longitudinal study
exploring perspectives of participants regarding reflective
practice during their transition from higher education to
professional practice. Reflective Practice: International
and Multidisciplinary Perspectives. 10, 2, 219-232.
Mann K, Gordon J, MacLeod A (2009) Reflection and reflective
practice in health professions education: a
systematic review. Advances in Health Sciences Education. 14,
4, 595-621.
Norman I, Ryrie I (2009) Mental health nursing: origins and
traditions. In Norman I, Ryrie I (Eds) The Art and
Science of Mental Health Nursing: A Textbook of Principles
and Practice. McGraw Hill, New York NY.
Shah A (1993) An increase in violence among psychiatric in-
patients: real or imagined? Medical Science Law. 33, 3,
227-230.
Stickley T, Stacey G (2009) Caring: the essence of mental
health nursing. In Callaghan P, Payle J, Cooper L (Eds)
Mental Health Nursing Skills. Oxford University Press, Oxford.
Washer P (2009) Talking with other health professionals and
patients' families. In Washer P (Eds) Clinical
Communication Skills. Oxford University Press, Oxford.
AuthorAffiliation

Correspondence
[email protected]
Sarah Dolphin is a staffnurse, Westlands Inpatient Assessment
and Treatment Unit, Humber NHS Foundation
Trust, Hull
Date of submission
August 1 2012
Date of acceptance
October 18 2012
Peer review
This article has been subject to double-blind review and has
been checked using antiplagiarism software
Author guidelines
www.mentalhealthpractice.co.uk
DETAILS
Publication title: Mental Health Practice (through 2013);
London

LINKS
Linking Service
Terms and Conditions Contact ProQuest
Volume: 16
Issue: 9
Pages: 20-23
Number of pages: 4
Publication year: 2013
Publication date: Jun 2013
Section: Art &science | self-awareness
Publisher: BMJ Publishing Group LTD
Place of publication: London
Country of publication: United Kingdom, London
Publication subject: Medical Sciences--Nurses And Nursing,
Medical Sciences--Psychiatry And Neurology
ISSN: 146 58720
Source type: Scholarly Journals

Language of publication: English
Document type: General Information
ProQuest document ID: 1370335479
Document URL:
http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.p
roquest.com%2Fdocv
iew%2F1370335479%3Faccountid%3D27965
Copyright: Copyright RCN Publishing Company Jun 2013
Last updated: 2016-04-09
Database: ProQuest Central
http://WV9LQ5LD3P.search.serialssolutions.com?ctx_ver=Z39.
88-2004&ctx_enc=info:ofi/enc:UTF-
8&rfr_id=info:sid/ProQ:healthcompleteshell&rft_val_fmt=info:
ofi/fmt:kev:mtx:journal&rft.genre=unknown&rft.jtitle=Mental%
20Health%20Practice%20(through%202013)&rft.atitle=How%2
0nursing%20students%20can%20be%20empowered%20by%20re
flective%20practice&rft.au=Dolphin,%20Sarah&rft.aulast=Dolp
hin&rft.aufirst=Sarah&rft.date=2013-06-
01&rft.volume=16&rft.issue=9&rft.spage=20&rft.isbn=&rft.btit
le=&rft.title=Mental%20Health%20Practice%20(through%2020
13)&rft.issn=14658720&rft_id=info:doi/
https://search.proquest.com/info/termsAndConditions
http://www.proquest.com/go/pqissupportcontactHow nursing
students can be empowered by reflective practice

72013, Vol. 17, No. 3
Key Words: reflective practice, reflective
pedagogies; RN-to-BSN students,
nursing education
The Making of a Butterfly: Reflective
Practice in Nursing Education
A butterfly gracefully flutters from
one flower to the next, taking nectar from
each flower, but also leaving pollen behind.
Imagine the expert nurse effortlessly
floating around the unit, meeting the needs
of the patients with her knowledge and
intuition and prepared for any setback.
The expert nurse gains a bit of knowledge
with each patient cared for, taking a piece
of the experience with her, while leaving
a part of herself with the patient in the
holistic care provided.

Nursing is truly a work of art that
requires a balance of many ways of knowing
at once. The transformation of caterpillar
to butterfly or student to nurse is part of
a process. The nursing student learns and
experiences the nursing world through
classroom and clinical education. The
student goes to a safe and comfortable place
to reflect on and explore self, newly gained
experiences, and knowledge. Eventually,
with time, reflection, and practice, the
student nurse will evolve into a nurse.
Therefore, the question becomes, what
is the nurse educators’ role in this
transformation and in what ways might we
assist in this journey? This paper explores
the phenomenon of reflective practice in
RN-to-BSN students. With reflective

practice being the cocoon in which nursing
students truly mature and prepare to spread
their wings.
What is Reflective Practice?
There are different epistemologies and
ontologies in reflective practice. Reflective
practice was first documented with the work
of Greek philosopher, Socrates. Socrates
would lead exploratory discussions, in
which a group or person would examine
their knowledge on a topic and their
personal beliefs about it. This technique is
still used in many classrooms and is known
as Socratic discussions (McEntee et al.,
2003). Socrates’ most famous student,
Plato, continued this philosophical inquiry
by urging students to perform ontological
investigations by questioning their ideas
and values (Kuiper & Pesut, 2004). In the

nineteenth century, Florence Nightingale
wrote her reflections on nursing, thereby,
introducing reflective practice to the
nursing profession and forever changing
it (LaSala, 2009).
Reflective practice goes beyond the
revisiting of an event by taking the
practitioner on a journey of self-discovery
to become a better practitioner (McEntee
et al., 2003). This journey allows for the
exploration of knowledge, skills, values,
beliefs, experiences, myths, and needs that
ultimately lead to clarified conceptual
meanings and heightened self-awareness
(Asselin, 2011; Durgahee, 1997; McEntee
et al., 2003; Palmer, Burns, & Bulman,
1994). Reflective practice can be a form of
self-assessment (Cook, 2011). Reflective

practice can also be a spontaneous action
wherein the nurse pauses to consider a
decision regarding patient care, in what
Watson (2008) calls “caring consciousness”
(Palmer et al., 1994).
Reflective practice is the cyclic process
of internally examining and exploring an
issue of concern, triggered by an experience,
which creates and clarifies meaning in terms
of self, existing knowledge, and experience;
resulting in a changed conceptual perceptive
and practice (Asselin, 2011; Beam, O’Brien,
& Palmer, 1994). Palmer et al. (1994) and
Beam et al. (2010) suggest the use of Gibb’s
reflective cycle (Figure 1) to guide students’
reflections (Gibbs, 1988). Gibbs (1988) uses
the reflective practice process as a guide
for experimental learning. For the purposes

of this study, a form of guided reflective
practice was used, in which reflective
thoughts are articulated in words, either
written or verbal, with the assistance of
guiding questions or other tools.
Reflective Practice in the Literature
Critically thinking is an essential skill for
a nurse. In the fast-paced nursing world,
nurses need to be able to think-on-the-fly
and be confident in their decision-making.
Nurses must have the courage to nurse and
The Making of a Butterfly: Reflective
Practice in Nursing Education
Jessalyn F. Barbour, MSN, RN, OCN
Notre Dame of Maryland University
Abstract
Reflective practice is the cyclic process of internally examining
and exploring an issue
of concern, triggered by an experience, which creates and
clarifies meaning in terms
of self, existing knowledge, and experience. This is a
descriptive phenomenological
study that explores the guided reflections of eighteen RN-to-
BSN students. The themes

derived from the student text include (a) reflection in-action;
(b) reflection on-action
in daily nursing practice; (c) time, autonomy, experience, and
fear were identified as
barriers. By integrating reflective pedagogies into nursing
curriculum, nurse educators
can help students develop competence in reflective practice and
enhance their learning
for a lifetime.
8 International Journal for Human Caring
The Making of a Butterfly: Reflective Practice in Nursing
Education
to question the status quo. Every novice
nurse dreams of being Benner’s (1984)
expert nurse, who floats through the day and
can think-on-the-fly to make decisions with
no disruption of care. Reflective practice
is a powerful process that contributes to the
making of a quality, expert nurse. Reflective
nursing practice empowers nurses in both
the educational and professional realms.
There are numerous benefits of reflective

practice. Reflective practice provides
experiential learning opportunities (Benner,
Sutphen, Leonard, & Day, 2010; Palmer,
et al., 1994). A qualitative study of eight
nursing students showed that reflective
practice enhanced learning (Bradbury-Jones,
Hughes, Murphy, Parry, & Sutton, 2009).
Another study evaluated the effects of a
reflective practice bachelor of science in
nursing (BSN) curriculum model, which
resulted in National Council Licensure
Examination (NCLEX) pass rate of greater
than 95% (Walker, Tilly, Lockwood, &
Walker, 2008). Being able to self-teach is
an important skill to have in the nursing
profession. The use of reflective practice
in education can assist nursing students to
learn from practice and to self-teach so that

they are better able to meet the challenges
of the professional nursing world (Benner
et al., 2010).
Reflective practice assists in the
cultivation of critical thinking skills in
students (Benner et al., 2010; Cook, 2011).
It has the ability to strengthen Carper’s
(1978) four patterns of knowing: empirical,
esthetical, personal, and ethical knowledge
(Davis, Taylor, & Casida, 2011). Reflective
practice prepares the nurse to ask the right
questions in the clinical practice setting and
notice slight changes in their patient’s status
(Picard & Henneman, 2007). Furthermore,
reflective practice can improve
communication skills in nursing students
(Durgahee, 1997).
Reflective practice is a journey of self-

discovery that leads to better practitioners
(McEntee et al., 2003). A study by
Bradbury-Jones, et al. (2009) shows an
increase in students’ self-awareness after
the implementation of reflective practice.
Reflective practice increases the likelihood
of the nurse providing ethical and holistic
care (Gustafsson, Asp, & Fagerberg, 2007).
A study on the use of reflective practice in
surgical nurses shows a positive correlation
between reflective practice and authentic
nurse-patient relationships (Flanagan, 2009).
Reflective practice cultivates presence,
which is an essential element of relational
engagement with patients (McMahon &
Christopher, 2011; Picard & Henneman,
2007) and leads to more individualized
nursing practice (Flanagan, 2009). A study

that examines the effects of reflective
practice on RN-to-BSN students shows that
it changed the nurses’ practice perspectives
and actions (Asselin, 2011).
Reflective practice can be used to
help bridge the theory-practice gap by
encouraging examination, exploration,
and connections (Benner et al., 2010;
Davis et al., 2011; Smith & Jack, 2005).
Reflective practice has the potential to
decrease stress in nurses’ professional
lives (Palmer, et al., 1994) and promotes
integrity, balance, and morality (Bjarnason
et al., 2009). It has been shown to promote
the development of intuition, which is the
essence of the expert nurse (Benner, 1994;
Hannigan, 2001).
While reflective practice can be a

beneficial tool and process, it also has
limitations. There is limited research on
reflective practice in nursing education in
the United States. There are also barriers
involving students and reflective practice.
Some students are not open to the idea of
reflective practice (Benner et al., 2007;
Kuiper & Pesut, 2004). They feel vulnerable
exposing their thoughts and feelings to
others, they feel uncomfortable with their
DDeessccrriippttiioonn- What
happened?
FFeeeelliinnggss- What were
you thinking or
feeling?

EEvvaalluuaattiioonn- What was
good & bad about the
experience?
AAnnaallyyssiiss- What sense
can you make of this
situation?
CCoonncclluussiioonn- What else
could you have done?
AAccttiioonn PPllaann- What
will you do if you are
in this situation again?

Figure 1. Reflective Practice Cycle (adapted from Gibbs, 1988)
92013, Vol. 17, No. 3
Education
own emotions, and/or they are satisfied with
their current level of competence (Asselin,
2011; Benner et al., 2010; Kuiper & Pesut,

2004). Time is a major barrier for nurses
and students to practice reflective practice
(Beam et al., 2010; Bradbury-Jones et al.,
2009; Picard & Henneman, 2007; Smith
& Jack, 2007).
Exploration of RN-to-BSN Students
Use of Reflective Practice
A nursing student’s educational journey
can be enhanced with reflective practice,
both spontaneous and guided. In addition,
reflective practice in the nurse can improve
practice. So the question becomes, do
RN-to-BSN students use reflective practice?
How do they use it? What obstacles do
they encounter that discourage
reflective practice?
Study Design
This is a descriptive phenomenological
study.

Study Setting
The study took place at a private
university in Baltimore, Maryland.
Study Sample
The sample included 18 RN-to-BSN
student essays from two accelerated
contemporary nursing trends and theory
courses.
Study Procedure
Week two of six in the contemporary
nursing trends and theory course was an
online class. It consisted of a slideshow
presentation on the Nursing Code of Ethics
and various activities, all to be completed
within one week. One of the activities was to
read an article on reflective nursing practice
and then answer the following questions in
a one-to-two page essay:
(a) In what ways do you engage in

reflection about your nursing
practice? Tell a story or two using
rich descriptive language where
you show reflective practice and
what it means.
(b) In your experience, what allows
for and what gets in the way of
reflective practice?
Gathering of Student Text
The participants submitted typed essays
that were a response to the above questions.
The essays were not graded, but were a
pass/fail type item for participation in the
online class.
Interpretation of Student Text
and Text Analysis
The essays were reviewed and themes
were derived. Themes were validated by a
doctorate-prepared research consultant and

the study participants.
Results
Three major themes were identified from
the student text. Only the essays examining
the previously mentioned questions were
included (n=18).
Theme A: Nurses reflecting
in-action/thinking-on-the-fly
Most (n=16) of the nurses in this study
describe what Schön (1983) calls reflection
in-action. The nurses describe situations in
which they reflected while working and
make decisions and/or changes based on
these reflections. These nurses think-on-the-
fly and make decisions on the go. Many of
these nurses are experienced nurses who
have been in the nursing profession for years
and describe a time when they were less able
to perform reflective practice and less

confident in their decision-making abilities.
Jane states, “As a newer nurse, engaging in
reflection, happened after the experience
occurred.” Jane went on to explain that with
experience she was able to reflect while the
experience was happening, think-on-the-fly.
The majority of the reflections in-action
revolves around ethical or moral issues and
the nurses dealing with difficult situations.
Some (n=4) describe asking themselves,
“How would I like to be treated if I were the
patient?” These reflections led to decisions
in which the nurses advocate for their
patients. These reflections also allow the
nurses to provide more individualized
patient care. A few nurses discuss the
exploration of their feeling while in-action,
which allow for improved decision-making.

Reflection in-action is also used by
the nurses to help them prioritize. Many
claimed that this ability came with
experience. Some nurses even describe
reflecting with their peers throughout the
work day. This collegial support aided them
by increasing their confidence in their
decision-making abilities.
A number of the nurses (n=4) stated
that reflection in-action allowed them to
link theory to practice. Many described
the application of theory into their daily
practice and the solidifying of theory
when they actually saw it in action. Shari
describes her nursing education and states
that “during clinical rotations, things began
to become clearer and all the textbook
knowledge became significant” once it

was seen in action.
Theme B: Nurses reflecting
on-action/retrospectively
All (N = 18) of these nurses practice
reflection on-action, which is the examining
of an event after it has occurred (Schön,
1983). This type of reflection does not
appear to be related to experience. Many
nurses also use this method to deal with
ethical or moral issues. However, this
retroactive reflection rarely changed the
event reflected on, but rather allowed the
nurses to make changes to their practice and
methods in the future. Reflection on-action
allowed the nurses to change and improve
their nursing practice. They describe being
able to learn from experience. Amy
describes reflective practice as “simply

learning from my experiences and providing
the best possible care based on those
experiences…I reflect to grow professionally
and personally.”
Reflection on-action allows these nurses
to examine themselves and explore their
feelings. This produces a self-awareness
and confidence within the nurses. Self-
assessment allows the nurses to make
appropriate changes and to be aware of their
limitations in practice. Reflection on-action
allows the nurses to have a more holistic
and open-minded view. Many nurses discuss
the concept of authentic nurse-patient
relationship and the importance of their
presence in their patients’ care. Mary states,
“I will remember that patients and their

families need us so the pumps can blare,
and the phones can continue to ring.” Mary
discusses the importance of just being there
for her patients when they need her and not
allowing tasks to get in the way. Some even
state that this action helps prevent burn-out
syndrome. All of these products of reflection
on-action lead to higher quality and more
holistic nursing care.
Theme C: Barriers
One obvious barrier is experience;
practice makes perfect. Those nurses with
more experience were better versed in
reflective practice. Other barriers include:
fear of emotions and self-exploration; time;
and lack of autonomy.
Time appears to be the most common
obstacle for nurses trying to engage in

reflective practice. Many described a fast-
paced and hectic environment in which they
had no time for reflective practice. Others
described heavy workloads and high acuity
patients, which left little time for anything
else. High nurse-patient ratios were also
mentioned as a barrier to reflective practice.
A few nurses report that having to perform
multiple roles and being pulled in many
directions was time consuming and left
little time for anything else. Bethany states,
“New technology and experimental life
sustaining techniques also add a complexity
to caring for our patients that leaves little
time for reflection.”
Another barrier that is frequently
mentioned is the lack of autonomy in
nursing. Many of the nurses in this study

feel that policies and procedures dictate
how they practice; they feel restrained by
organizational rules and regulations. Allison
said, “With so many rules and regulations
that require enormous amounts of time spent
on documentation, it is not hard to see why
many nurses have become so focused on
completing tasks in nursing and lose sight
of the caring aspect nursing was founded
on.” This leads into another barrier that the
nurses discuss, nursing’s obsession with
tasks and documentation, which takes the
focus off the patient, caring, and reflective
practice. Lastly, the nurses discuss the lack
of autonomy due to administration and
physicians. These limitations and barriers
can be hard for nurses to overcome,
especially when they are inexperienced and

lack the tools needed for reflective practice.
Discussion
It is well known that the gaps between
theory and practice in nursing need to be
bridged and that a curriculum revolution in
nursing education is underway. In order for
nursing education to produce holistic nurses,
its curriculum must be balanced. One
possible way to aid in this journey is the
use of reflective practice.
This study has shown that practicing
nurses in a RN-to-BSN program use
reflective practice on a daily basis. This
skill has aided them in many ways. It allows
nurses to learn from experience and make
changes to their practice to provide higher
quality care. Reflective practice assists the
nurse to be truly present and aware of

themselves and the patients they care for.
It promotes the unificati on of theory and
practice. Reflective practice supports nurses
in being morally and ethically sound in
their care. It encourages continued growth
by way of self-assessment and self-
awareness. Lastly, it fosters a more holistic
nursing approach.
Reflective practice should be taught
during nurses’ initial education. It is an
important and valuable skill to have.
Reflective practice should be used and
developed throughout the nursing program
curriculum, that way the novice and
beginning nurses are able to use it
immediately upon entering practice. “The
process of learning to learn from experience
is as important as the end product of the

learning, namely an ability to view a
phenomenon from a different perspective
and translate new knowledge into action
(Palmer, et al., 1994).” Learning to learn
is a valuable gift that nurse educators can
bestow upon nursing students to use in the
rapidly changing nursing world.
Implications for Practice
There are numerous ways that reflective
pedagogies can be used in nursing curriculum.
In order to be successful, reflective practice
must be interwoven throughout the curriculum.
Much of the nurse’s clinical education is
experimental learning. To be effective, the
environment must be safe, rich, and provide
opportunities for reflection (Benner, et al.,
2010). Many times reflective practice is
completed orally during clinical post-
conference or simulation de-briefing. Wherein,

the clinical instructor will ask the students to
talk about their experience while offering
questions for the group to reflect upon
(Diekelmann, 2003). Another method is
reflective journaling. Usually, students will
require some guiding questions for their
journals, but eventually reflective journaling
becomes like second nature. Reflective journals
are used to encourage the students to analyze
an experience and determine the best approach
to use in the future by examining the literature.
Students can be transformed by these
experiences, but only if they are able to notice
and acknowledge the experiences (Benner
et al., 2010). Nursing students must be engaged
and play an active role in their learning.
These methods of reflective practice can
also be used in the classroom. The nurse

educator can facilitate Socratic discussions,
where the students are encouraged to open
themselves to new ideas and knowledge
and to question the status quo. A case study
or a lived experience that expands a student’s
boundaries of knowledge can be reflected upon
through group activities or narrative papers.
Blogs and discussion boards can be used to
have reflective conversations in the online
classroom (Davis, Taylor, & Casida, 2011).
Education
112013, Vol. 17, No. 3
Education
There are many other ways of using
reflective practice in the classroom setting.

The possibilities are endless. Reflective
practice assignments can assist the nurse
educator in knowing whether the student is
truly comprehending content and making
the appropriate connections between theory
and practice. Reflective practice is not an
ends to a means, it is a cyclic process that
should continue throughout a nurse’s career.
Reflective practice must be used in
combination with other student-based and
practice-based teaching strategies (Benner
et al., 2010; Palmer et al., 1994). Reflective
practice must be integrated into an entire
program’s curriculum in order to obtain
holistic results (McEntee et al., 2003).
Nursing instructors must be well versed
in reflective practice, in order to lead and
guide students thru the reflective process

(Palmer et al., 1994). Reflective practice
has immense potential in nursing academia.
Conclusion
Reflective pedagogies should be
integrated into nursing curriculum. The
literature, the experts, and this study elucidate
the potential that the reflective practice
phenomenon has for enhancing nursing
education and practice. While technology
and procedures may change, reflective
practice is a skill nurses can use for their
entire career. By guiding students through
the process of reflection and providing them
with a safe space for reflection, nurse
educators can help them develop competence
in reflection and enhance their learning for
a lifetime. Nurse educators are in a position
to provide nursing students with the tools

needed for self-learning. There are numerous
reflective practice techniques that can be
used in nursing education and some can even
be used as a means of assessment. Reflective
pedagogies have the ability to transform
nursing education and nursing practice.
Reflective practice can assist in the
transformation of a student into a balanced
nurse. Essentially, reflective practice supports
the making of a butterfly – an expert nurse.
References
Asselin, M. (2011). Using reflection
strategies to link course knowledge to
clinical practice: The RN-to-BSN student
experience. Journal of Nursing
Education, 50, 125-133.
Beam, R., O’Brien, R., & Neal, M. (2010).
Reflective practice enhances public
health nurse implementation of nurse-

family partnership. Public Health
Nursing, 27, 131-139. doi:10.111/j.
1525-1446.2010.00836.x
Benner, P. (1984). The Dreyfus model of
skills acquisition applied to nursing.
In P. Benner, From novice to expert:
Excellence & power in clinical nursing
practice (pp. 13-38). Upper Saddle River,
NJ: Prentice Hall Health.
Benner, P., Sutphen, M., Leonard, V., & Day,
L. (2010). Educating nurses:
A call for radical transformation.
San Francisco: CA: Jossey-Bass.
Bradbury-Jones, C., Hughes, S., Murphy, S.,
Parry, L., & Sutton, J. (2009). A new way
of reflecting in nursing: The Peshkin
approach. Journal of Advanced Nursing,
65, 2485-2493.

Caper, B. (1978). Fundamental patterns of
knowing in nursing. Advances in Nursing
Science, 1(1), 13-23.
Cook, P. (2009). Critical thinking in the
health professions In D. Bjarnason,
M. Carter, & S. Prevost (Eds.), Legal &
ethical issues: To know, to reason, to act
(pp. 49-63). Nursing Clinics of North
American, 44(4). Philadelphia, PA:
Elsevier.
Davis, L., Taylor, T., & Casida, D. (2011).
In-class & electronic communication
strategies to enhance reflective practice
(pp. 47-63). In M. Bradshaw & A.
Lowenstein (Eds.), Innovative teaching
strategies in nursing & related health
professions (5th ed.). Sudbury, MA:
Jones & Bartlett.

Dewey, J. (2005). How we think (electronic
version). New York. NY: Barnes & Noble
Books.
Diekelmann, N. (Ed.). (2003). Teaching the
practitioners of care: New pedagogies for
the health practitioner (Vol. 2). Madison,
WI: University of Wisconsin Press.
Durgahee, T. (1997). Reflective practice:
Nursing ethics through story telling.
Nursing Ethics, 4, 135-146.
Flanagan, J. (2009). Patient and nurse
experiences of theory-based care.
Nursing Science Quarterly, 22, 160-172.
doi:10.1177/0894318409331937
Gibbs, G. (1988). Learning by doing: A
guide to teaching & learning methods.
London, England: Further Unit
Education.

Gustafsson, C., Asp, M., & Fagerberg, I.
(2007). Reflective practice in nursing
care: Embedded assumptions in
qualitative studies. International Journal
of Nursing Practice, 13, 151-160.
doi:10.111/j.1440-172X.2007.00620.x
Hannigan, B. (2001). A discussion of the
strengths & weaknesses of ‘reflection’ in
nursing practice & education. Journal of
Clinical Nursing, 10, 278-283.
Kinsella, E. (2009). Professional knowledge
& the epistemology of reflective practice.
Nursing Philosophy, 11, 3-14.
Kuiper, R., & Pesut, D. (2004). Promoting
cognitive & metacognitive reflective
reasoning skills in nursing practice: Self-
regulated learning theory. Journal of
Advanced Nursing, 45, 381-391.

LaSala, C. (2009). Moral accountability &
integrity in nursing practice (pp. 423-
434). In D. Bjarnason, M. Carter, & S.
Prevost (Eds.), Legal & ethical issues: To
know, to reason, to act. Nursing Clinics
of North America, 44(4). Philadelphia,
PA: Elsevier.
McEntee, G., Appleby, J., Dowd, J., Grant,
J., Hole, S., & Silva, P. (2003). At the
heart of teaching: A guide to reflective
practice. New York, NY: Teachers
College Press.
McMahon, M., & Christopher, K. (2011).
Toward a mid-range theory of nursing
presence. Nursing Forum, 46(2), 71-82.
Palmer, A., Burns, S., & Bulman, C. (1994).
Reflective practice in nursing: The

growth of the professional practitioner.
Oxford, England: Blackwell Scientific.
Picard, C., & Henneman, A. (2007). Theory-
guided evidence-based reflective
practice: An orientation to education for
quality care. Nursing Science Quarterly,
20(39), 39-42. doi:10.1177/0894318406
296783
Schön, D. (1983). The reflective practitioner.
New York, NY: Basic Books.
Smith, A., & Jack, K. (2005). Reflective
practice: A meaningful task for students.
Nursing Standard, 19(26), 33-37.
Walker, C., Tilley, D., Lockwood, S.,
& Walker, M. (2008). An innovative
approach to accelerated baccalaureate
education. Nursing Education
Perspectives, 29, 347-352.

Watson, J. (2008). Nursing: The philosophy
& science of caring (Rev. ed.).
Boulder, CO: University Press
of Colorado.
Education
Author Note
Jessalyn Barbour, MSN, RN, OCN is an oncology clinical
educator at Anne Arundel Medical Center in Annapolis,
Maryland and an
adjunct professor at Notre Dame of Maryland University’s
School of Nursing.
This research was not supported financially by any grants or
organization. Many thanks to Mary Packard, PhD, RN and
Nadja Muchow,
MS, RN, CBN for their support and assistance with this study.
Correspondence concerning this article should be addressed to
Jessalyn Barbour, 4th Floor - Oncology, Anne Arundel Medical
Center
2001 Medical Parkway, Annapolis, MD 21401. Electronic mail
can be sent via Internet to: [email protected]

Copyright of International Journal for Human Caring is the
property of International
Association for Human Caring and its content may not be
copied or emailed to multiple sites
or posted to a listserv without the copyright holder's express
written permission. However,
users may print, download, or email articles for individual use.
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,
ABSTRACT
Nursing students in the 21st century are entering highly
complex health care systems that require advocates for so-
cial justice and human rights on behalf of patients. Nurses
are well positioned as patient advocates. This article pres -
ents a brief overview of the historical and theoretical per -
spectives underpinning emancipatory knowing and pro-
poses several methods nursing faculty can use to empower
nursing students to provide care informed by this way of

knowing. Nursing faculty are urged to adopt a curriculum
that supports an emancipatory and caring praxis and to
mentor students to provide care supportive of social jus-
tice, particularly for the vulnerable and marginalized mem-
bers of society. Nursing students who learn to embrace and
value emancipatory knowing during their educational pro-
gram may likely continue this praxis after they graduate.
[J Nurs Educ. 2014;53(2):65-69.]
T
he complexity of the health care system and chaotic clin-
ical environments beckons nurses who can conceptual-
ize and integrate emancipatory knowing into their clini-
cal practice. A praxis of emancipatory knowing offers nurses a
means to refl ect and act in a manner that advocates for social
justice and human rights on behalf of the patients for whom
they care each day (Chinn & Kramer, 2011; Cowling, Chinn,
& Hagedorn, 2000; Falk-Rafael, 2005; Harden, 1996). Specifi -
cally, emancipatory knowing is the aptitude to acknowledge
social and political “injustice or inequity, to realize that things
could be different, and to piece together complex elements of
experience and context to change a situation as it is to a situ-
ation that improves people’s lives ” (Chinn & Kramer, 2011,
p. 64). Understanding the concept of emancipatory knowing
and its theoretical basis is essential to knowing how to integrate
it into practice. This way of knowing, derived from multiple
perspectives and theories, offers a relevant addition to nursing
research, theory, and practice (Chinn & Kramer, 2011). For
many nurses, the basis for understanding this concept may or
may not commence during their educational program, as it may
depend on their program philosophy, curriculum structure, and
the philosophical values and beliefs of the nursing faculty who
teach them. Given these different variables, contextualizing
emancipatory knowing may vary among nurses. Nursing stu-
dents, who learn to embrace emancipator y knowing as praxis,

may likely continue doing so after they graduate. The purposes
of this article are to present a brief overview of the historical
and theoretical perspectives that led to the conceptualization of
emancipatory knowing, to discuss its signifi cance to nursing,
and to offer examples of how nursing faculty can empower stu-
dents to integrate emancipatory knowing into clinical practice.
HISTORICAL OVERVIEW
Historically, nurses have confronted power imbalances
throughout their educational programs and careers. Emancipa-
tory efforts in nursing history are often blended with feminist
views, particularly during the feminist movement of the 1960s
and 1970s and as characterized by Jo Ann Ashley in her book
Hospitals, Paternalism, and the Role of the Nurse (1976; Chinn
Emancipatory Knowing: Empowering Nursing
Students Toward Refl ection and Action
Marianne Snyder, MSN, RN
Received: February 19, 2013
Accepted: September 11, 2013
Posted Online: January 7, 2014
Ms. Snyder is Assistant Professor of Nursing, Department of
Nursing,
University of Saint Joseph, West Hartford, Connecticut.
The author thanks her doctoral academic advisor, Dr. Carol
Polifroni,
University of Connecticut School of Nursing for her support.
The author has disclosed no potential confl icts of interest, fi
nancial
or otherwise.
Address correspondence to Marianne Snyder, MSN, RN,

Assistant
Professor of Nursing, Department of Nursing, University of
Saint Joseph,
1678 Asylum Avenue, West Hartford, CT 06117; e-mail:
[email protected]
doi:10.3928/01484834-20140107-01
Journal of Nursing Education • Vol. 53, No. 2, 2014 65
EMANCIPATORY KNOWING
& Kramer, 2011). In this book, Ashley (1976) traced the histori -
cal roots of oppression in nursing through a feminist lens and
presented a laudable critique of a patriarchal health care system
and the ongoing struggles of nurses who strive to gain control
over their education and practice. It was also during this period
that the concept of empowerment entered the nursing literature
(Bradbury-Jones, Irvine, & Sambrook, 2007; Hage & Lorensen,
2005; Kuokkanen & Leino-Kilpi, 2000; Manojlovich, 2007;
McCarthy & Freeman, 2008) and stimulated lively debate and
discourse within the nursing community. Despite more than
30 years later, these struggles persist, but not without the per -
severance of those who believe that change initiated through
emancipatory efforts does occur. Emancipatory knowing is a
call to action to advocate for social justice in a system that con-
tinues to permeate inequities and oppression among the masses
(Chinn & Kramer, 2011).
Throughout history, nurses have consistently advocated
for improved health conditions for individuals, families, and
communities, with a primary focus on addressing immediate
health care needs and educating people about health promo-
tion. Nursing care in the 21st century requires nurses to practice

with a broader emphasis on the historical, social, and political
structures in society (Clare, 1993; Falk-Rafael, 2005; Ford &
Profetto-McGrath, 1994; Harden, 1996; Kagan, Smith, Cowl-
ing, & Chinn, 2010; Kuokkanen & Leino-Kilpi, 2000; Rose &
Glass, 2008) to understand the impact of these factors on the
health and well-being of individuals, groups, and communities.
Chinn and Kramer (2011) introduced emancipatory know-
ing to the nursing literature and credited the infl uence of
several
theories and perspectives when they developed this concept.
The following discussion about these infl uential theories and
perspectives aims to explicate the importance of integrating
emancipatory knowing into the curricula to help broaden nurs-
ing students’ awareness about hegemonic beliefs embedded in
the sociopolitical system and to support their capacity to ques -
tion the status quo.
THEORETICAL INFLUENCE
The concept of emancipatory knowing was developed
through an eclectic process that integrated concepts from other
theories and perspectives, namely critical theory, the postmod-
ernist and poststructuralist views of Freire (1995) and Foucault
and Gordon (1980), and White’s (1995) sociopolitical pattern of
knowing (Chinn & Kramer, 2011). Important to the process of
helping a student develop this way of knowing is a caring and
transformative teacher who guides students to learn beyond a
technical model of health care and instead uses an emancipa-
tory model to emphasize refl ection and action (Ford &
Profetto-
McGrath, 1994; Owen-Mills, 1995).
Critical theory initially emerged during the 1920s from a
synthesis of ideas offered by philosophers from the Institute
for Social Research in Frankfurt, Germany, commonly referred

to as the Frankfurt School (Harden, 1996; Ray, 1992). The un-
derlying premise of critical theory includes three basic tenets
about knowledge—specifi cally, knowledge must be practical,
emancipatory, and have the potential to liberate the oppressed
(Kagan et al., 2010). In the 1960s, Habermas (1987) restruc-
tured critical theory by blending philosophical and sociological
perspectives to develop critical social theory (CST) grounded
in rational communication, as described in his theory of com-
municative action. Habermas’ (1987) theory offers a framework
to explain how modern society creates many social injustices.
A principle tenet of CST is to help oppressed people liberate
themselves from known and unknown societal oppression;
hence, CST offers a framework to study and conceptualize the
social and political factors infl uencing society (Chinn &
Kramer,
2011; Ray, 1992; Wells, 1995).
Much of the CST literature is rooted in the work of Freire and
his pedagogy for liberation of the oppressed masses (Bradbury-
Jones et al., 2007; Freire, 1995). Freire (1995) contended that
the oppressed often subsume the worldview of their oppressor,
thinking that doing so will lead to greater power and control. In
reality, this social conformity often leads to marginalization of
the oppressed group and results in low self-esteem and low self-
worth (Roberts, 1983). Dialogue that asks questions of “how,”
“what,” and “why” as related to the various power structures
and relationships that exist in society helps frame a contextual
basis for nurses to understand the infl uence of these affi
liations
on certain individuals and groups in society.
Discourses or symbolic representations in our culture shape
how we view our world and learn what is socially valued or dis -
counted (Chinn & Kramer, 2011). For example, White (1995)
expanded on Carper’s (1978) empirical, ethical, personal, and

esthetic patterns of knowing and added sociopolitical knowing
as a means to understand the sociopolitical and cultural contexts
that infl uence perceptions of health and illness, identity, lan-
guage, and relationship with society. Chinn and Kramer (2008)
developed emancipatory knowing and distinguished it from so-
ciopolitical knowing because it “embrace[s] a wide[r] range of
historical and contextual considerations, and… emphasize[s]
the fundamental intent to seek freedom from conditions largely
hidden that restrict the realization of full human potential”
(pp. 87-88). Foucault’s poststructuralist philosophy about power
imbalances created through discourse provides additional in-
sight to understand emancipatory knowing (Chinn & Kramer,
2011). When new knowledge and power gain momentum and
infi ltrate the prevailing discourse, they can serve once again to
infl uence thought and alter future actions.
These theoretical and philosophical perspectives elucidate
how sociopolitical, cultural, and historical factors can infl
uence
human action. Developing an awareness of these factors, as
well as a belief in personal capacity to change, is an important
step toward advocacy and social action. Nurses are well posi -
tioned as health care leaders to advocate for social changes that
mitigate oppression. To support this call, nursing students need
support to exercise their power to apply an emancipatory praxis
throughout their profession.
CALL TO ACTION
Some believe that nursing is not as prepared as it could be
to address the plethora of health care challenges faced each day
by individuals and groups (Chinn & Kramer, 2011; Falk-Rafael,
2005). Nursing education programs would do well to heed this
call
to action by adopting a curriculum that supports a caring praxis

66 Copyright © SLACK Incorporated
SNYDER
and mentors students to provide care supportive of social
justice,
particularly for the vulnerable and marginalized members of so-
ciety. To acquire an aptitude for emancipatory knowing, nurses
need to develop a broader understanding of the sociopolitical
forces that compromise the ability of a person, family, or
commu-
nity to fl ourish, free from oppression, within their world.
Interest
and support for integrating emancipatory approaches into
nursing
education and curriculum development have increased (Bevis &
Murray, 1990; Fontana, 2004; Ford & Profetto-McGrath, 1994;
Glen, 1995; Harden, 1996; Lipp, 2003; Parker & Faulk, 2004;
Randall, Tate, & Lougheed, 2007; Schreiber & Banister, 2002).
Nursing is called to closely examine the disciplinary practices
that suppress, rather than support, nurses who question assump-
tions and challenge the status quo (Kagan, Smith, Cowling, &
Chinn, 2010). Nurse educators can support this call to action by
examining current pedagogical practices that minimize student
critical thought and action pertaining to the curriculum or
clinical
experiences. Teaching guided by emancipatory action may help
create a foundation for nursing students to integrate similar ap-
proaches into clinical practice.
FACILITATING STUDENT EMPOWERMENT
The following section presents a variety of methods that ed-
ucators can integrate into nursing curricula to guide students to-

ward an emancipatory praxis. The Table outlines each method
and the dimensions of emancipatory knowing to facilitate the
outcomes. It is anticipated that these approaches will inspire ad-
ditional dialogue about other effective strategies to help nursing
students embrace a broader understanding of the environments
in which they practice.
Randall et al. (2007) suggested using critical questioning as
an emancipatory method in teaching and learning, where the
teacher and student engage in a “co-creating dialogue meant to
serve as a trigger for thinking” (p. 61). This form of questioning
aims to guide the student through open and nonjudgmental dia-
logue to explore what specifi c knowledge guided their actions
while caring for a patient (Randall et al., 2007). In addition,
students who are able to share their experience of caring for a
patient using exploratory dialogue and questioning are likely
to increase their inquisitiveness as related to factors outside the
patient’s immediate diagnosis (Bevis & Murray, 1990; Randall
et al., 2007). Students who are empowered to refl ect critically
about clinical situations and ask questions about why certain
problems exist, how they can be resolved, why they occur, and
who benefi ts will learn to develop a deeper understanding of
their patients’ circumstances (Chinn & Kramer, 2011; Harden,
1996; Kagan et al., 2010). Use of critical questioning can help
nursing students to incorporate principles of emancipatory
knowing into their practice and offers those for whom they care
a voice to navigate the complexities of the health care environ-
ment.
Another strategy to enhance emancipatory knowing is to use
fi lms to stimulate refl ection and action. Films provide a
platform
TABLE

How nursing students can be empowered byreflective practic

How nursing students can be empowered byreflective practic

Recommended

Recommended

More Related Content

More from PazSilviapm

More from PazSilviapm (20)

Recently uploaded

Recently uploaded (20)

How nursing students can be empowered byreflective practic