Ways of Knowing in Nursing Read the article, Sherman, D. W. (1997).? Death of a newborn: Healing the pain through Carper’s patterns of knowing.?Journal of the New York State Nurses Assoc

Death of a newborn: healing the pain through Carper's patterns of knowing in nursing. By: Sherman DW, Journal of the New York State Nurses Association, 00287644, 1997 Mar, Vol. 28, Issue 1

Database: CINAHL

Death of a newborn: healing the pain through Carper's patterns of knowing in nursing

During a six-week childbirth education course, I teach expectant couples ways to cope with the physical changes they can expect during pregnancy and delivery, as well as the emotional changes they might go through. I encourage them to draw on personal experiences and accomplishments, which will enhance their sense of inner strength and lessen their fears. I tell my pregnant couples they can call me if they have any questions, concerns, or problems related to their birth experience or during the postpartum period. Living in rural upstate communities, many young couples have moved far from the support networks of family and friends, so I extend my role to that of a "community" nurse who offers guidance and encouragement in the early days of parenthood.

Jane and Jim Olsen enrolled in my Lamaze class to relieve their anxiety about childbirth. After several infertility work-ups and one miscarriage, this pregnancy was a testimony to their love and commitment to each other. They wanted to do everything possible to insure the health of their baby and a positive birth experience. They diligently attended class, read numerous books about childbirth, and openly discussed their fears and expectations. I promised to share with them everything I knew about childbirth. My knowledge was gained through graduate education in parent-child nursing, ASPO certification as a childbirth educator, and through my own lived experiences of pregnancy, birth, and parenthood.

Although in Lamaze classes I discuss all possible variations in birth experiences and potential birth complications, I focus on birth as a natural process, requiring intense work, which most often culminates in the joyful birth of a healthy child. The possibilities of death of a newborn or mother are approached as an unlikely reality, given the expertise and technology offered by current prenatal and obstetrical care.

Yet my work on a high-risk obstetrical unit has etched in my memory the grief and loss experienced by parents who have lost their newborns. Such experiences involve intense nurse- patient relationships requiring not only scientific knowledge and skill, but a nurse's love, respect, empathy, obligation, and commitment. Through this work, I realized the importance of encouraging grieving parents to spend time with their critically ill newborns, and in the event of death, the opportunity to hold their son or daughter as they mourned a life that was never given a chance. Some health providers and family members express concern that this would add to parents' pain. Yet I reamed that amid the suffering and loss, the healing process can begin. As parents hold and kiss their babies, the nightmares about deformed, monster-like children are put to rest. Looking at their newborn's features, mothers and fathers recognize family traits and

decide on names. This is not only important in coming to terms with reality, but it gives them tender memories of their precious infants to hold close to their hearts.

Jane and Jim Olsen had already experienced the grief and loss of having a first-trimester miscarriage. As we shared the excitement of childbirth through our Lamaze classes, I didn't know that one day I would be called upon to holistically integrate empirical, esthetic, ethical, and personal knowledge to help this couple heal the pain of their newborn's death. I realize now that my teaching and nursing practice were guided by what Carper (1978) describes as "patterns of knowing in nursing."

Keeping a Promise

One evening early in May, my phone rang. Through his tears, Jim pleaded "Please come to the hospital. We need you right away!" I quickly made arrangements for my own children and sped off to the obstetrical unit of our community hospital. When I entered the unit, the nurses greeted me saying "Your Lamaze couple, Jane and Jim Olsen, are still in the recovery room. The delivery went okay, and the baby looked perfectly nominal, but she had trouble breathing and we couldn't resuscitate her." I asked if Jane and Jim had seen and held their baby. The nurse answered, "No, we don't do that."

I instantly asked myself, "Do you know what to do for this grieving couple?" The answer was yes. I had the nursing education and background to make a difference. I must be their advocate and do everything possible to support them in their grief and create a healing experience. As I had promised, I would share with them everything I knew about childbirth. Now I must go one step further and integrate the science and art of nursing with the ethical obligations of an advocate and my personal knowledge, all ways of knowing in nursing, in facing not only birth but death.

Ways of Knowing in Nursing

Each nurse-patient interaction is a holistic expression of different patterns of knowledge in nursing. Although nursing education provides the scientific knowledge and critical thinking skills to decide the appropriate course of action in many nursing care situations, the wholeness and complexity of human experiences require nurses' openness and receptivity to other forms of knowing.

To provide excellent nursing care, nursing knowledge must extend beyond the descriptions, explanations, and predictions offered by the scientific method to an appreciation of patterns of knowledge involving the symbolizing, understanding, and creating of human experiences? Symbolizing is the identification of reality and description of the situation or experience as it is. Understanding involves a search for meaning van explanation of the patient's experience. Creating focuses on the imagined possibilities, and the potentials of a given event or experience (Chine & Jacobs, 1987).

Carper's (1978) four "patterns of knowing" are interrelated and link nursing theory and nursing practice. The patterns of knowing are identified are empirics or the science of nursing, esthetics

or the art of nursing, ethics, the moral component of nursing knowledge, and personal knowledge in nursing derived from one's own lived experiences. As distinct aspects of the whole of nursing knowledge, each is vitally important and may be communicated either through words or by a nurse's behavior and actions.

Healing Through Empirical Knowing in Nursing

Empirics as a pattern of knowing is based on the assumption that what is known is observed through the five senses and can be verified by others. Empirical knowledge is thus factual in nature, and its processes involve describing, explaining, or predicting phenomena of concern to nursing. Empirics contributes to nursing knowledge by offering the descriptive knowledge regarding disease, illness, and technology. Empirical knowledge answers the critical question "What is this?" (Chine & Jacobs, 1987; Chinn & Kramer, 1991).

The art of nursing engages nurses in the critical life events of those for whom we care. I hoped that through my presence, Jane and Jim felt a sense of comfort and support. I held them both and cried with them. I listened as Jane sobbed, "This is not the way it's supposed to be!" I gently wiped her tears.

I knew what this baby meant to them. They had been trying to conceive for the past four years, and this baby was a source of joy and fulfillment. Jane had done everything possible to ensure the health of her baby. She ate well, avoided alcohol, got plenty of rest, and vigilantly kept her prenatal appointments. Jim was extremely proud and protective of his wife, taking over any of her strenuous household chores, working two jobs so that lane could reduce her work hours, and rubbing Jane's belly as he talked to his unborn child. Even Jane's mother attended a class with her daughter and son-in-law, expressing her excitement about becoming a grandmother.

After six weeks of class, I had developed a supportive relationship with this couple and I understood the importance of offering them the opportunity to see and hold their baby. I said, "I know you're both in pain right now. I've reamed that it helps many couples work through their grief if they spend time with their baby. If this is your choice, I will be there for you. I will bring you your baby."

In caring for this couple, I entered as fully as I could into their experience. Understanding the meaning of this experience for them, both as individuals and as a couple, guided my nursing conduct, attitudes, and actions. Imagining the possibilities, I envisioned the beginning of a healing process made possible by physical, emotional, and spiritual support. Through my nursing actions, they would be able to caress her little body, hold her close to their hearts, tell her of their love and hopes of being good parents, choose her name, and even possibly plan a funeral which would celebrate her short life and lay her to rest. With knowledge and support, Jane and Jim would be empowered to act, based on their own personal values and choices.

Healing Through Ethical Knowing in Nursing

Ethical or moral knowledge in nursing includes not only ethical codes of behavior, but a focus on what ought to be done in a situation. The symbolic dimension of ethics is the process of

clarifying a situation or experience, while the understanding dimension is rooted in one's own philosophic beliefs and values. Through the creating dimension of ethics, guidelines for advocacy are developed to promote or protect the rights and interests of others. Thus, ethical knowledge involves actively confronting conflicting values, norms or standards. Rather than prescribing the ways things should be done, ethical knowledge provides insights into possible alternatives or decisions, with an emphasis on individuality and human respect. Ethical knowledge involves such critical questions as "Is this right? For whom? Is this responsible?" (Chine & Jacobs, 1987; Chinn & Kramer, 1991).

From the moment I asked the nurses if my couple had seen and held their baby and was told "No, we don't do that," it was clear that I had a responsibility to advocate for their rights and best interests. In responding to the issue of what ought to be done, I knew that this couple must be given options in their grief, and opportunities that might enhance their ultimate healing and sense of wholeness and dignity. I have argued many times from an ethical perspective that dying people should have the right of unlimited access to their loved ones. In the event of neonatal death, it is ethically just that loved ones, such as Jane and Jim, also have the opportunity to spend time with their baby, if they so desire. Through confronting the norms or standards in the care of parents experiencing neonatal death, I needed to clarify with the nurses my role, giving reassurance of the value of my knowledge and experience, and assisting both the nurses and my couple in recognizing the potentials of all the alternatives and decisions.

In speaking with the nursing care coordinator of the unit, I reamed that many of the nurses on this unit were uncomfortable and inexperienced in caring for grieving parents. Since I had worked at that hospital in a supervisory position in previous years, I had developed collegial relationships with the nursing supervisor and staff. We agreed that I would accompany the nursing care coordinator to the morgue and take responsibility for bathing, dressing, and bringing the baby to her parents if they so wished. I would then spend as much time as needed with the family during the visit. I assumed the responsibility of providing holistic nursing care in this situation. I also accepted the nursing staff's request to conduct an in-service program on coping with neonatal death.

Healing Through Personal Knowing in Nursing

Personal knowledge in nursing evolves from a nurse's inner knowledge of self with the symbolic dimension described as an opening to the fullness of the life and a conscious awareness of life experiences. The understanding dimension of personal knowledge involves introspective awareness of the meaning of the patient's experience based on the nurse's own personal life experiences. Through the creative dimension of realizing, nurses are able to express an authentic, genuine self in interactions with others. Personal knowledge therefore allows nurses to enter the world of their clients through a deep understanding of their experience and with an intuitive sense of its importance. The critical questions asked by the nurse are "Do I know what to do? Do I do what I know?" (Chine & Jacobs, 1987; Chinn & Kramer, 1991).

The next morning, Jane called me to ask if I would bring them their baby.

Her parents and Jim were on their way to the hospital. Once again, I asked myself "Do I know what to do?" With knowledge, courage, and conviction, I answered yes.

With the nursing care coordinator, I went to the morgue and cared for the baby. Wrapping her tightly in a pink blanket, and placing a pink-bowed hat on her head, I covered any evidence of the autopsy. I went upstairs by the back elevator, holding this dead baby girl in my arms, realizing how much she felt like the doll I used in Lamaze classes. With a prayer for strength, I brought her to her parents and grandparents. As they took her from my arms, I cried. As a mother myself, I felt their pain and anguish. Yet over the course of three hours, as I came in and out of their room, I saw them begin to accept their baby's death. Their faces revealed a sense of peace and comfort. They remarked on her beauty as they gently touched her face and stroked her hands. They took turns holding and rocking her, caring for her as if she were alive. With their eyes and hearts filled with love, they named her Mary, a sweet and holy name for "their little angel."

The greatest sorrow that I have experienced as a nurse was taking this baby from her mother's arms. All I could leave with them was a lock of her hair, and the blanket in which she was wrapped. This was my gift of love for a couple entrusted to my care. To this day, I cry when I recall that moment.

The symbolism, understanding, and creating dimensions inherent in Carper's patterns of knowing in nursing were made clear to me through this extraordinary nursing experience. Through years of nursing education and practice, I had acquired the knowledge, values, courage, and strength which enabled me to care for this family. The ways of knowing in nursing had become an integral part of who I was and how I practiced. I resumed home weary but with a sense of fulfillment. I believed that I had made a difference in the lives of this couple and family.