Journal of Clinical Nursing 1992; 1: 161-166

Exploring the knowledge of nursing practice

BARBARA VAUGHAN MSc, RGN, DipN, DANS, RNTProgramme Direetor, Nursing Developments, King's Fund Centre, 126 .-ilbert Street, LondonNWI 7NF, UK

Accepted for publication 14 January 1992

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Summary

This paper describes the very personal experience of a senior nurse's struggle to• •si'M'y 1 try to come to understand the nature of nursing knowledge more clearly. Miss

Vaughan was working as a Senior Lecturer in the School of Nursing Studies atthe University of Wales, and this paper reflects her attempt to bring together theexperience of practice with those concepts that were being presented to herthrough the formal literature. The paper: •• «' i ?.:•: i*̂

• commences with an honest description of the dilemmas which were facing her,,,.j^. at the time and her concern that she had begun to lose touch with the real world

of nursing.

• she then identifies her personal reflections through the use of a daily diary.

>mxih -; • finally the relationship between theoretical concepts relating to clinical nursingand her personal perceptions and feelings in practice is explored.

nursing practice, nursing knowledge, refiiection.

It is never possible to share another person's experiencetotally, nor is it easy to try to find the right words toexpress what is often thought to be intuitive in nature.There is a fine line between being open and honest andappearing to be overconfident and a balance has beensought between these two extremes. I have used the firstperson throughout this article because, by its very essence,it describes a personal experience. Thus the style ofpresentation is rather unconventional. The very nature ofjournals, which provide a source for some of the material,is that they are private and part of what I have tried toexpress would be lost if I had been bound by the formalityof academic form.

Return ing to pract ice

In order to set things into context (and context is critical)there arc sonic things which need lo be explained initially.

Firstly, for many years I have been firmly convinced thatin order to know nursing it is necessary to practice nursing.The essence of what we are lies in what we actually dorather than in what we say we do. Inherent in this notion isthe need to practice; and I have had a growing 'dis-ease'over the last couple of years that I was forgetting what itfelt like to nurse. Furthermore I had been advocating therole of lecturer practitioner (Vaughan, 1989) which wasbeing followed by others, but there were warning bells thatI was retreating further and further away from practicemyself. In response to this disquiet I negotiated entry intoa local clinical unit, which was near enough to my place ofwork so that I could visit on a regular basis. However, mypurpose was not to go as a lecturer or a clinical teacher butto be a practitioner myself. What I hoped for was somemutual gain for both the unit staff" and myself, in that Iwould be able to offer them some support to develop areasof their practice while they would give me space to nurse—

161

162 B. Vaugban ( M l l o l . i . ' I

and most importantly, from my perspeetive, tbere was tbeneed to become involved in clinical work on a day-to-daybasis.

Finding tbe time to do tbis was very difficult. Tbe onlyway I eould arrange to go to tbe ward was between 7.30 amand 10.00 am before going off to attend to other commit-ments. In terms of time tbis was very little but it basprovided me witb a wealtb of stories wbicb I baveattempted to incorporate into this article to illustrate whatI am trying to convey. 'y. - ,n.>-m,t ;

Reflections from a journal

Tbe second issue to raise is the idea of reflection in actionand on action (Scbon, 1983). Tbis can be achieved bykeeping a journal and was sometbing which I had theoret-ically advocated for a long time but which I had been veryconscious that I had not actually been doing. Some of thestudents I worked with assured me that I was reflectingwith them but, as I bave now discovered, this is a verydifferent thing from that which is gained by sitting downwith pencil and paper and actively exploring tbe personalaspects of an experienee (cf. Holly, 1987). 'Talking' withmy own journal has meant that things could be said whichI may not have been prepared to express in public andtrying to find tbe words to express wbat were often verysubjective feelings sharpened the way in which I con-sidered them. Therefore a private journal started toemerge at this time, and some of the records are used here.

Learning from experience

What did I learn therefore from this experience. Firstlythere was a very strange response wbich I can onlydescribe as energizing, whicb occurred through practice.As I dragged myself out of bed at 6.00 am I wondered whatI was doing this for; it felt like some form of masochism.As I went back to the office at 10.00 am I had a feeling ofelation, almost a high, which filled me with energy. Yet allI had been doing was being with people, washing, toilet-ing, helping with breakfast, etc.—all those so-called basicnursing tasks which are deemed to be simple but which arefundamental to nursing. However, there was also some-thing special about 'being with' patients, or as Benner(1984) says 'presencing', which was an intensely privilegedposition because it took me into what can be called theprivate domain of peoples' lives.

I wrote not long ago (Vaughan, 1990), albeit briefly,about tbe intensely private nature of nursing. Tbe acts thatgo on between a patient and a nurse are so firmly bedded inthis private domain that they arc not talked about in the

pub or over tbe dinner table. Wbile everyone will happilydiscuss publicly their operation or medical problem, veryfew are prepared to talk about the sort of things whieh goon between a nurse and a patient.

'I cried and the nurse comforted me. I wet the bedand she made it all right. I felt dirty and she made mefeel clean again. I couldn't get to the loo alone but Iwasn't embarrassed with the nurse.'

These are not the sort of things which people normallydiscuss because they usually occur in private, even in ourown homes. What we, as nurses, deal in is so intenselypersonal that it doesn't get addressed in public- yet I feltan intense privilege that people appeared to trust meenough to let me into this private part of their lives. It wasas if they would sometimes lie there in such a vulnerablestate but let you in there with them. I began to wonder,therefore, whether it was this mutual 'trust' which wasfeeding me with energy. Recently I came across a publica-tion by Jocclyn Lawler (1991) 'Behind the Screens' wbichalso discusses these issues. She suggests that: 'the essenceof these practices had not been regarded as formal know-ledge, partly because tbere bas been no formal language todescribe them', and indeed I have only been able toexpress them to you in personal terms. The suggestion isthat: 'the "invisibility" of nursing is linked witb theseconcepts (body care, privacy, dirty work, etc.) and with tbelack of an academic discourse on the body as a whole.' YetI cannot help wondering if it's this intense privilege whichis part of what make.s nursing so .special and gave me theenergy to carry on working.

Competent to practice?

One of the things which really worried me was that Iwould find that I was no longer competent, yet aloneexpert, in the practice of nursing. Having been stronglyinfluenced by tbe work of Benner (1984) and Benner &Wrubel (1989), I was very conscious that I bad noknowledge of tbe context in wbicb I was working let alonethe medical speciality (vascular surgery). It was all unfam-iliar to me and I wondered if I would be able to functionbeyond the level of an advanced beginner. Here, byreturning to my journal I can share with you what tookplace. Firstly, I didn't 'feel' totally incompetent. Not onlywas I able to contribute actively in some areas but I wasable to pick up on things whieh seemed to have becomelost in the milieu of day-to-day practice. For example, weheard about Martin (not his real name) at report and botbtbe student I was working with that morning and I had thedistinct impression that he was a 'difficult' and not verybright person, not so much from what was said but from

Exploring the knowledge of nursing practice 163

how it was said. Later that morning as we chatted withMartin while we made his bed, he suddenly commented onthe static (from the hed) and the fact that there was openoxygen in the room, asking us if this was a potential firerisk. That is not the sort of comment you expect from a'not very bright' person. On reflection with the student weboth found that his comments had 'shocked' our initialideas about this man. We had not expected to have such aconversation with him. This raised the question of why, orwhether, his behaviour was different with us. Why had wefound him interesting and open while others had not? On apersonal level I found myself wondering whether he wasactually clinically depressed — he had every right to he,being a relatively young man with a fairly dense hemi-paresis and minus one of his legs, yet he had been 'labelled'as difficult. However, the other issue might be somethingto do with our behaviour. We chatted with him and shareda bit of ourselves and maybe in return he was prepared toshare a bit of himself with us. What was also interesting tome was that I didn't sec him again for 2 weeks (one of thenegative things about this experience) yet when I walked inhe actually remembered my name from one 'briefencounter'. I don't know what was happening here butperhaps there was something about 'reciprocity', a need togive and take. There appears to be little evidence ofsharing in nursing, nevertheless I cannot help wondering ifthis has a 'meaning' which is highly significant to thosewho are being cared for. However, I also wonderedwhether the fact that I had had a 'rest' from clinical carefor a while meant that I also had more energy and saw theworld of patients with new eyes. Maybe there arc lessonshere about the need for sabbaticals, job swapping foragreed periods of time, or similar activities which may givethose who arc practising continuously some time and spaceto recharge their batteries.

'Personal knowing'

One of the other things which came out of this particularexperience was connected with discovering somethingabout myself. Martin had shaved himself and missed a partof his face, 1 suspected that he had a lack of awareness ofthat side of his body following his stroke (drawing on mysomewhat rusty physiological knowledge!). I couldn't re-member the correct terminology hut didn't feel that thisreally mattered. For my part I had an intense desire to takethe razor and finish the shave for him. Here I was,therefore, advocating self-care or independence but in thepersonal domain of knowledge (after (larpcr, 197(S) I alsofound this strong need to 'do things for people'—possiblytied up with a mothering instinct of protection. I suspect

that this is true of many nurses and I was perhaps moreaware of it having just read some unpublished work fromHelen Cox's journal (Deakin University) who hadexpressed similar feelings. The question is, however,whether I would have discovered this of myself if I had notactively reflected on the experience.

Returning to the idea of levels of expertise, there are twoother stories to describe. Quoting again one lady who saidto me just as I was leaving: 'I've been very privileged tohave you this morning haven't I?', and another who said 'Idon't let everyone, but you can call me Jane', going on tosay 'You are a Sister aren't you?'

I didn't wear a uniform and introduced myself asBarbara, a nurse from the school. Did they recognizesomething in the way I worked which suggested that I wasto be trusted, that I knew what I was doing or that I was anexperienced nurse? Why was it that I was asked aboutdiagnoses and prognoses when I was a relative stranger?Maybe it was the grey hairs and wrinkles which come withmaturity or some other tacit knowledge which I wasdrawing on from years of practice.

A student was with me on one of these occasions and herexplanation was that it was something to do with 'presence'(I don't think she had read Benner's work at that time), butshe couldn't find other words to express why this recogni-tion had taken place. Certainly, even though I openly saidthat I would have to check some technical aspects of care(about drugs, skin preparation, timing in relationship tomobility, etc.) the patients demonstrated a trust whichappeared significant to me.

Understanding experience—a theoreticalinterpretat ion

Because there is so mucb which can be learned frompractice, the remainder of this article could be taken upwith further descriptions of my clinical experiences. How-ever, what I must do now is to try to gather these ideas intosome kind of understanding from an epistemological per-spective.

C .̂arpcr (1978) argues that there are four domains of'knowing' in nursing:• the empirical or scientific knowledge,• the personal knowledge of self,• the aesthetic knowledge, sometimes called artistry,• the moral knowledge which influences any act.She suggests that all these forms of knowledge aredrawn on in every nursing act although some arc moreovert (and more valued in the scientific world) than others.I was certainly very conscious of all four in my practice.

164 B. Vaughan

For example recognizing Martin's loss of awareness camefrom an empirical knowledge bedded in the biologicalsciences even though I could not always remember thecorrect terminology. There was personal knowledge aboutself, my need to 'do things' but also my comfort inpractising (which was very surprising to me). There weremoral aspects of where I should be and of how much Ishould/could interfere when I .saw things which I woulddo dififerently: the wash bowls were stacked—a primemedium for bacterial growth; and the morality of thesurgeon's apparent wish to amputate an elderly lady's legwho had 'had enough' and was quite determined not toundergo surgery despite a badly necrotic and painful foot.Also, there were the artistic aspects of 'presencing', skillsof mobility and patient handling, and some lack of skill inknowing how to perform some of the technical aspects ofcare. Even though I could sometimes work them out fromfirst principles I had lost some of the 'fiuidity'.

On a more formal front I have also tried to gain anunderstanding of this experience through the work ofHabermas (1972) and have been helped in my understand-ing by such authors as Smyth (1986), Carr & Kemmis(1986), and Pearson (1990). Habermas suggests threecategories of knowledge, the technical interest, the prac-tical interest and the emancipatory interest. For manyyears it has been the technical interest which has gainedsupremacy in being recognized as some form of 'superior'knowledge. It not only gains respect in the scientific, butalso the political world and has become all powerful ininfluencing the social and political arena. This form ofknowledge looks for absolutes, it seeks truth as somethingwhich is static and holds a high degree of certainty. Itsplace may well be in the firm high ground of formaltheoretical enquiry using mainly a positivist (cause andeffect) mode of enquiry based on controlled experiments. Itseeks certainty and predictability, which as Smyth (1986)points out is fine in 'the high moral ground . . . of researchbased theory for seeking resolutions of our problems . . .',but as he suggests, drawing on Schon's (1983) workbecomes incomplete and discredited when we 'descendinto the swampy lowlands where situations are murky andcharacterised by confusing "messes" with no easy resolu-tion.'

How easily these words can be related to nursing.According to Pearson (1990):

'Technical interest relates to the empirico-analyticalparadigm, grounded in the instrumental scientifictradition. In nursing it encompasses technical and

: procedural competence and draws on theoreticalknowledge which infbrms the performance of psycho-motor skills and predicts cause and effect'.

On a personal front I have to add that it intrigues me as towhy this form of knowledge holds such weight in scientificand political worlds because as time moves on, it is so oftendisproved or fbund to be invalid; many of the scientificbases on which we found our 'judgements' are discreditedwith time. s.. ,> ,

The second major area identified by Habermas concernswhat he calls practical knowledge, a term which could beconfusing to us as nurses because it is much more than'getting on with the practical work' and is bedded in theworld of meanings, of human interaction and of'intersub-jective meanings of human interaction.' In terms ofenquiry this is the field where interpretative work comesinto play using phenomenological approaches to try tograsp meaning. Thus the work of Benner (1984), MacLoed(1991) and others has been moved by this paradigm to tryto understand the meaning of nursing. However accordingto Smyth (1986), Habermas suggests this form of know-ledge has its limitations too, 'since it has the inherentlimitation of being unable to question the content or thecontext of communication. The consequence for him(Habermas) is that knowledge of this kind becomes sys-tematically distorted because ofthe continuing existence ofextant social, political and cultural practices'.

It can be argued that this is in fact a very rich source ofunderstanding in nursing because it is so deeply concernedwith interpersonal meaning and has much to offbr. How-ever like so many other things it cannot complete the wholepicture.

The third category, that of emancipatory knowledgerelates to the critical paradigm and is primarily concernedwith the ability to:

'act rationally, to reason self consciously and to makedecisions on the basis of available knowledge andneed'. (Pearson 1990) ;,:::!( vt;ii.

According to Carr & Kemmis (1986):'the form of reasoning appropriate to the "practicalsciences" (after Aristotle) was called praxis . . .because it is informed action which, by reflection onits character and consequences, reflexively changesthe "knowledge base" which informs it'.

They suggest that craft is not refiexive and does not changetradition (although I am unsure about this on a personalfront). Praxis, they suggest has a characteristic, not presentin craftsmanship, which implies that 'the social setting willbe reconstructed . . . it remakes the conditions of informedaction and constantly reviews action and the knowledgewhich informs it.' Through praxis a dialectical concernoccurs, where two opposites may meet and a synthesis issought in developing a new understanding. It is active andproductive. For example, it may challenge espoused and

Exploring tbe knowledge of nursing practice 165

used theory, what I 'know' and what I 'do'. Contradictionsmay arise which require exploration to increase under-standing of the meaning behind what is happening. Whatis so positive about this school of thought is its recognitionof the other two approaches, which so often reject eachother. However there is a suggestion that without emanci-patory knowledge we can become impotent to act, tochange, develop, grow and take control of ourselves. It isthe type of 'knowing' which can lead to autonomy, toempower nurses and the nursing world in which theywork, to manage and control their own lives. Sadly it is alsothe world which I see least well developed in practice,where again there are stories which reflect oppression and aperceived inability to act and change things. Alternatively,I would also suggest that there are times when some nurseshave very eflectively found ways of covertly having muchmore control than would be apparent. There may be amoral debate here and this could be an area of enquiryworth pursuing.

How, therefore, does all this relate back to my earlierstory telling. I suggested at the beginning that one of myfears of returning to practice arose from reading Benner'swork, which so firmly bases skill in context. Wbile I retaina strong admiration for ber work, somebow it did not restcomfortably with what 1 was experiencing and one answerfor this may be that the paradigm which has driven herenquiry is largely based in the world of meaning, i.e. theinterpretative paradigm. In order for fluidity and expertiseto occur in nursing there is a need to be competent in allaspects of the work, the technocratic having real meaningwithin the context of each area. Even though there is noway in which 1 would dispute this interpretation, there wassomething else which did not quite feel right. It is Watson(1985) who talks ahout the core, or very essence of nursing,and the tritn or context-related components. It may bethat, in a novel situation, one can be more competent tbanexpected, but tbe unfUtniliar context, and the emphasis otitechnocratic knowledge may lead to a lack of confidence. Itcould therefore be argued that confidence, possibly gainedthrough emancipatory knowledge, of what one does, atidwhat one does not know, is a necessary and critical part ofcompetence. If the core of nursing is valued in its ownright and artistic and emancipatory knowing are deemed torest alongside technocratic knowing in importance thenthere appear to be areas of nursing knowledge which movewith you where ever you go. In Benner's work this wouldappear to be so, however there is no discussion or debateabout the transferability of some aspects of competence.

Exploring what was happening has lead me to believetbat someone can, in fact, be at different levels of com-petence in different domains of knowledge. Certainly from

my experience I would suggest tbat I was far fromcompetent in the technocratic domain at that time, al-though I would add that I suspect this is the easiestdomain to work in. I didn't know all the drugs; I could notalways remember all tbe physiological answers to localproblems; 1 didn't always know the significance of dif-ferent tests and investigations, all of which limited mypractice. However, I could learn these things relativelyeasily from a textbook. What I could understand wasfear, a need to know, loneliness in company, pain andcomfort . . . things which lie in the practical knowledgedomain of interpersonal skills. According to the valuesystem from which I come these are the things whichconstitute the essence of nursitig and within this field Ifound that I do still have a degree of expertise whichtravels with me, albeit still in need of developing. It willnot stand alone and to gain expertise I would have much tolearn in the technocratic domain but what I had was notwithout value.

Furthermore as I have grown older and learned more Ifind I have also gained a greater degree of 'emancipatoryknowing' and I suspect that it was this which was recog-nized by some of tbe patients. It may be important to saythat, from my perspective one of the critical features ofemancipation is a recognition of the context in which oneis, and the contribution of all tbe factors within thatcontext. Hopefully this respect for others is one way ofpreventing those who perceive themselves as emancipatedfrom becoming oppressors all over again. However, if thereis not a degree of self respect amongst us as nurses for whatwe have to offer ourselves then it will be even moredifficult for others to recognize the value of the service.

I have come to feel that reflection, through writing ajournal, has been critical to tbe development of thisunderstanding. Through active interplay between what Iknow through propositional knowledge (book knowledge)and that which I feel or experience, a dialect, has, and iscontinuing to develop, which makes me botb academicallyand clinically curious. However, I would add that as acolleague has said to me, having been distanced frompractice and returned, albeit briefly, maybe I have 're-fbund nursing' and there may be a lesson for all of us there.The intensity of practice is such that it could be necessaryto step back occasionally in order to gain respite from thevery essence of presencing. This may be one way toprevent tbe so-called burnout (cf. Bailey, 1985) which hasgained such credence in the 198()s.

I am not at all sure that I have come to terms yet withsome of the more theoretical issues which are underlyingwhat I am trying to express. Maybe as Polyani (1958) said1 'know more than I can tell'. What I am fairly sure about

166 B. Vaughan

is that while there is an inextricable link between thesethree forms of knowledge, which are all needed in practice,it is possible to work at different levels in different fields ofknowing and that all the time we need to be open toreviewing where we are. That the knowledge sources areinterdependent rather than hierarchical in relationshipneeds to be addressed in order that a wider range ofnursing skills can be acknowledged.

Let me finish with a quote from Carr & Kemmis whichexpresses some of the ideas that I have tried to voice.

'In short, taking theories too much for granted leavesus at the mercy of yesterday's good ideas. While tosome extent we do this, just because practices whichhave "worked" seem validated by our experience, weshould remember that the phenomena of social life aredifferent from those of physics and chemistry. Whilethere are some general tendencies and well attestedsocial "facts" real practical situations are idiosyn-cratic, social conditions often change unpredictably,and different points of view lead us to judge similarsituations differently.'

References

Bailey R,D, (1985) Coping With Stress in Caring. Blackwell ScientificPublications, Oxford.

Benner P, (1984) From Novice to Expert. Addison Wesley, Califor-nia,

Benner P, & Wrubel J, (1989) The Primacy of Caring. AddisonWesley, California,

Carper B, (1978) Fundamental Patterns of Knowing in Nursing.Advances in Nursing Scienees 1(1), 13-23,

Carr W, & Kemmis S, (1986) Becoming Critical: Knowing 'ThroughAction Research. Deakin University Press, Victoria,

Habermas J, (1972) Knowledge and Human Interest. Heinemann,London,

Holly M,L, (1987) Keeping a Personal-Professional Journal. DeakinUniversity Press, Victoria.

Lawler J. (1991) Behind the Screens: Nursing, Somology and theProblem of the Body Churchill Livingstone, London,

MacLoed M, (1991) Kxpericnce in everyday nur,sing practice: astudy o f experienced' surgical ward sisters, PhD Thesis, Univer-sity of Edinburgh,

Polyani M, (1958) Personal Knowledge: Towards a Posl-criticalPhilosophy. Routledge and Kegan Paul, London,

Pearson A, (1990) Nursing: From Whence to Where. Deakin Univer-sity, Victoria.

Schon D, (1983) The Reflective Practitioner. Temple Smith, Lon-don,

Smyth W,J, (1986) Reflection-in-Aetion. Deakin University Press,Victoria.

Vaughan B, (1989) 'Two Roles, one job'. Nursing Times 85 (11), 52,Vaughan B, (1990) Caring—a hidden value. Nursing Standard.

4 (25), 26,Watson J, (1985) Nursing: Ihe Philosophy and Science of Caring.

Colorado Associated University Press, Colorado,

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