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Advances in Nursing Science Vol. 38, No. 2, pp. 73–82 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
An Interview With Dr Barbara A. Carper Elizabeth R. Eisenhauer, RN, BSN, MLS In 1978, Dr Barbara A. Carper’s foundational work, “Fundamental Patterns of Knowing in Nursing,” arguably created a paradigm shift in nursing. However, her voice has been absent from the nursing literature in recent years. I was privileged to conduct a personal interview with Dr Carper in 2014. The edited interview includes a synopsis of her background, career trajectory, sources of inspiration, and her perspective on the current state of nursing. She reaffirmed her passion for reflective nursing practice, the importance incorporating the arts and humanities into nursing education, and using an integrated approach with the patterns of knowing in nursing. Key words: caring, Carper, epistemology, nursing practice, nursing theory, patterns of knowing, technology, ways of knowing
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N 1978, Dr Barbara Carper’s foundational work “Fundamental Patterns of Knowing in Nursing”1 appeared in Advances in Nursing Science and has subsequently been cited more than 1800 times in the professional literature.2 This highly influential work and other publications of Dr Carper’s such as “The Ethics of Caring”3 are so substantially related to my research on bioethics and informed consent that I became inspired to, or maybe obsessed with, investigating her cur-
Author Affiliation: School of Nursing, University of Michigan, Ann Arbor. The author has no conflicts of interest to declare. Funding: No funding was received specifically for this research. Elizabeth Eisenhauer is a recipient of the 2014-2016 Jonas Nurse Leader Scholar Award. The author thanks Dr Barbara A. Carper for allowing this interview; Dr Lienne D. Edwards for her assistance in contacting Dr Carper; Dr Cynthia ArslanianEngoren for being an excellent mentor and confidant; Dr Jacqueline Fawcett for her inspirational examples of interviews with the Nurse Theorists; and 3 anonymous reviewers for their helpful comments. Correspondence: Elizabeth R. Eisenhauer, RN, BSN, MLS, School of Nursing, University of Michigan, 400 North Ingalls, Ann Arbor, MI 48109 ([email protected]). DOI: 10.1097/ANS.0000000000000067
rent status. After some research and correspondence by mail, I was granted the privilege of a telephone interview with Dr Carper on July 28, 2014, and a personal meeting with her on August 25, 2014. This is an edited version, mostly from the telephone interview. Dr Carper was given the opportunity to make editorial changes prior to submission for publication. Final contributions were received, via telephone, from Dr Carper on February 17, 2015. Although Dr Carper initially described herself to me as a very “private person,” she was gracious enough to share some of her life story. Biographical information can be seen as an example of personal, aesthetic, and even ethical ways of knowing.4,5 In the interview, Dr Carper also reaffirmed her passion for reflective nursing practice, the importance incorporating the arts and humanities into nursing education, and using an integrated approach with the patterns of knowing in nursing. Not intended to be a theoretical or philosophical analysis of the patterns of knowing, the aim of the interview was to learn about Dr Carper’s background, career, and perspective on the current state of nursing. A follow-up manuscript, a scholarly analysis on how the patterns of knowing and Carper’s other work relate to research on informed consent and decision making, is in preparation. 73
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BACKGROUND EE: First of all let me thank you again for agreeing to do this interview. Your work is very well known and very influential and I’m sure will continue to be forever. Basically, there are 3 topics I would like to cover with you—your background, your career, and your perspective on the current state of nursing science. Could you please tell me a little bit about how you grew up or where you are from? BC: I grew up in Texas and Oklahoma during the 1940s and 1950s. I was raised by my grandparents for the most part. I couldn’t have asked for a better family. I had a large extended family so I was always surrounded by cousins and aunts and uncles. There was always someone to pick me up when I was a kid if I fell and scrapped my knee, or tell me not to do this or that! EE: What do you remember about deciding to become a nurse? BC: I think I was probably in high school and thinking about going to college. You know in the early 1950s it was a very different environment for women. Most people then thought that there were only a few choices that would be suitable for a woman. In those days, it would be extremely rare and maybe in some circumstances even impossible if a woman wanted to become an engineer or as physicist. My grandfather was absolutely wonderful. First of all, when I was in high school he made me take typing. He said a woman could always get a job typing, meaning a secretary or receptionist or something like that if she couldn’t get any other job. My grandmother had been a nurse during the late 1920s and 1930s. Of course, her background was very, very different. In those days, particularly where she grew up in Texas, you learned to become a nurse by being an apprentice to a physician. I remember that because during the second World War there was a real nursing shortage. So many nurses went into the military that she went back to work in a doctor’s office during the 1940s because he couldn’t find anyone to help. So she probably had an influence on me. She was also someone
prominent in the community. If someone had a sick child they would call her and she would go over and take a look and tell them if they needed to go to a doctor. Going to a doctor in those days wasn’t something people did unless they thought it was a very bad situation. Now people go if they have a runny nose and a cough. I think probably just seeing what she did and how she responded and how people responded to her; she was a very, very important person to that community. She was the person they relied on for advice or for help and I’m sure that had an influence on me. But I decided I wanted to be a nurse and of course in those days the usual route was the hospital program, but I said, “No, I want to go to college.” I didn’t want to just be a nurse. I loved literature and music; in fact that was what I really wanted to do in college, was major in music but my grandfather said, “Absolutely not!” He said, “You can’t make a living being a musician.” Of course in those days the expectation was—it doesn’t really matter about going to college because women were expected to get married and their husbands would provide. This was his expectation, too, but he said, “What if something happened to your husband and you had a family? At least you’d be able to do something.” At least he was thinking forward that much. So, I insisted that I wanted to be a nurse but I wanted to go to college. I could do both. EE: That’s excellent. That’s a fascinating story. I think a lot of that goes on today too— parents pushing children in career directions as opposed to any kind of art or liberal arts. BC: Oh, yes. I think it’s even more prominent today, in a sense, because we are such a technology-focused culture that they don’t see any point in the humanities for the most part.
CAREER EE: Please tell me about the trajectory of your career. BC: I went to college at Texas Women’s University. I graduated in 1959. We just had
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An Interview With Dr Barbara A. Carper our 55th class reunion. The College of Nursing there was 1 of the very earliest 4-year programs in Texas. I think I was in either the first or second class. I deliberately chose Texas Women’s University because I wanted to go to a women’s college. In the 1950s that was sort of against the grain. Most people my age after high school wanted to go to the larger coed university but I just thought there would be more opportunity at a women’s college to make choices that you might not otherwise have made; to concentrate on what you were really interested in and I was able to take advantage of some of those things—the music, some of the athletics, however, limited because the nursing program was extremely time consuming. We went 12, well 11 months a year, for 4 years. Then I did some clinical nursing and from my experience there I became very interested in being a nurse anesthetist. So I did go to the University of Michigan, to the Medical School there in Ann Arbor. It was either an 18-month or a 2-year program certification (in those days, it wasn’t a degree program but a certification program) and finished there and took my certifying exams as a nurse anesthetist. I did that for quite a few years and I liked it very much, but quite frankly, after several years I missed the patient contact. You had very brief contact, you spent hours with them but they were unconscious and then they were gone. I always wondered, “how did they do?” “What happened to them after we took them out of the recovery room?” So I decided then to go back and get a master’s degree. I went to Teachers College at Columbia University in New York and obtained my master’s degree. Then I went from New York to New Mexico to teach! Well, I wanted to see something different. I loved New York. I just took to Manhattan like a duck to water but thought I’d try something different. EE: And then did you teach in Texas? BC: Yes, after I finished my doctorate I went back to Texas Women’s University to the faculty there. By then it was quite a large program; they had not only the program on the main campus, which was in Denton few
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miles north of Dallas, but they had a clinical campus in Dallas and a clinical campus in Houston. They had expanded tremendously since I had graduated. I was there for quite some time. My last position there, I was a director of their PhD program. EE: And then you went to New Hampshire after that? BC: Yes, my husband and I decided to make that move for family reasons. We moved to a small town in New Hampshire and for the first 2 years we were there I commuted to Maine—to Portland—the University of Southern Maine. Two very good friends of mine (we had been classmates at Columbia), one was the dean [Audrey Conley] and one was the associate dean [Carla Mariano], somehow or other persuaded me to make that commute every week from New Hampshire to Maine. The University of Southern Maine had a fairly young graduate program, a master’s degree program, and so I went there for 2 years to be director of the graduate program—the master’s degree program—and particularly enjoyed it, but the commute particularly in New Hampshire winters was stressful. I decided the commuting was too much. There was a small, private, liberal arts college Colby-Sawyer in the town where I was living—New London, New Hampshire. They had just started a nursing program—I think it was 2 years previously—and the person who had started that program was resigning. So I took that job. That was almost building it from the ground up. They hadn’t even gotten to the point where they’d gotten the state board of nursing approval so that was an enormous challenge and extremely time consuming, but it was a wonderful setting! Nursing in the middle of this liberal arts college was [something] they didn’t quite understand. So I set about making connections with the liberal arts people, the humanities people, and they were a wonderful group of people and very soon I felt at home and at place there. And the nursing faculty! If I had hand-picked them I could not have gotten a better group. So that was a wonderful experience, working with all of those people, the nursing faculty
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and people particularly in the sciences that were so critically important for the nursing program. I was there until ‘89. Once our daughter finished college, again, for personal reasons, my husband and I decided to go further south and after some exploration and looking around— we came to the University of North Carolina at Charlotte, which had a very good undergraduate program and had, a few years before, established a graduate program master’s degree. They needed some experienced faculty and I saw a wonderful opportunity! I love to go into programs that are growing and changing rather than those that have reached the point where they think they are perfect and nothing needs to be altered. So, again, this was just like me going to New Mexico, when I came to the University of North Carolina at Charlotte, and I stayed there until I retired in 1999.
INSPIRATION AND INFLUENCE EE: It is fascinating to hear about you, Dr Carper. The fact that you were working with unconscious patients, I wonder how you think that influenced the “patterns of knowing”? BC: Well, I’d never thought about it that way. I could say, certainly, spending so many hours with an unconscious patient constantly monitoring and caring for in a way but without any communication between us, it probably did lead to why I decided to go back [to school]. That was for me a very important missing link—the patient. I decided it really was important enough to do something differently. As I said, I enjoyed the nursing; being a nurse anesthetist, it was also very demanding but again, it was just that missing link. I wanted to be conscious and present with another conscious and present human being who I was caring for. EE: So what do you think inspired you to write about the “ways of knowing”? BC: It was at the University of New Mexico, when I was teaching there [mid to late 1960s]
that I became aware of some of the personal concerns I had about what the curriculum focused on, what we went about emphasizing, and in some aspects what we ignored or paid little attention to or placed little importance on from a practice perspective. Science, and the science of nursing, had become the focus at that point in time. I think it would be a bit of an exaggeration to say that there was such a strong focus on the science that there was an exclusion of everything else, but science, the science of nursing, became “the elephant in the room.” But in my mind everything that surrounded nursing, that I thought was important to the practice of nursing, seemed to have become less important to the students, almost to the point where they thought, “it doesn’t count” or “if I don’t have time for that it doesn’t matter” and that bothered me very much because I thought there was more to nursing practice than the way we were approaching it at that point in time. After a while, I decided, “there is something missing here I would like to explore some more.” So that’s when I decided to go back and get my doctorate from Columbia, again, Teachers College, Columbia. EE: You mentioned something was “missing.” What was missing? Can you please provide an example? BC: A lack of consideration of ethics was missing from both education and practice. There was no real time devoted to the teaching of ethics. In nursing education, ethics was frequently restricted to teaching the Nightingale pledge. It was more rule-oriented than principle-oriented, in terms of the morality of [one’s] actions. Very few people were prepared to address ethics at that time. But there were very real, ethical, and moral concerns that I observed in practice. For example, it was common, accepted practice—not fully informing patients about their condition or their treatment. Information was frequently omitted. I can recall several instances of patients not being informed that they had a terminal illness, and their families were not informed either! That was very disturbing to me, and it wasn’t just a few
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An Interview With Dr Barbara A. Carper patients, that was the standard at the time. Most health care workers at that time did not see it as an ethical issue. Of course, clinicians varied; some provided more information than others. Some providers omitted information that would have been very important about making choices in terms of treatment. So, for me, developing the patterns of knowing was a response to intellectual and personal concerns to clarify and express that nursing practice was more than science; nursing practice was not limited to that. EE: Did other fields or theorists impact or influence your work? BC: In college, I became interested in philosophy and I did a considerable amount of reading just because I liked it. And over time, history, too, became something I very much enjoyed reading and learning about. I don’t mean dates, but intellectual history, cultural history, and there were some professors at Columbia who influenced me. I took more courses than I had to because it intrigued me. I took some philosophy courses, and at the time there was a wonderful professor of philosophy who did, I think, enormously influence me in my dissertation6 —Phil Phenix.7 He’s deceased now but I took his course, which probably had a major influence on what I decided I was going to do with my dissertation.6 There was another professor at Columbia that taught a course in cultural history, which I thoroughly enjoyed. I took 2 or 3 philosophy courses at Columbia and enjoyed every one of them. I particularly remember Dr Phenix.7 History reinforced the notion in my mind of context, how important context is. One professor that I took a course from wrote an article called “Meaning in Context: Is there any other kind?”8 And that really made me stop and think because, of course, there really isn’t, particularly when you are talking about relationships with human communication. Anything in which one has to relate to another, context becomes critically important. But context is also important in science. You don’t disregard the context in terms of interpreting the data.
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So, yes there have been a lot of people and books and ideas that have influenced me— that, as we all do, I just sort of . . . I thought about them sometimes over a period of several years, and it became incorporated in my perspective without stopping to cite the source, so to speak. There were several people too, after I wrote my dissertation. There have been some people, too, writing independently of me but I think they were very often on the same track. One of them in nursing is Pat Benner. When I read her book9 I thought, “Oh she got it. She got it!” EE: Yes. I was wondering what other nursing theorists you favor. You were a contemporary of people like Watson and Leininger. Did they influence your work at all or did you know each other? BC: Oh, yes in fact in the early days most of us knew each other! It was a small group so most of us knew each other one way or the other. And it was amazing . . . some of the discussions we’d have. You know, we’d go to a conference or a meeting and there’d always be some of the others there and the conversations we’d have over the dinner table! Yes, yes. Peggy Chinn and I were colleagues for quite some time. She is one of those people that we could, you know, sit down over lunch or whatever and have the most wonderful conversations! EE: I often think your views are much in line with Dr Peplau’s work. BC: Oh, yes, I knew her. Not as well as I knew some of the others but she was a remarkable woman. In fact they all were; we were all remarkable in our day and time! The whole army of us! EE: I’m sure that was fascinating. What do you think was going on in the late 1970s or early 1980s that generated so much new nursing theory at the time? BC: This was when nurses started getting interested in going back for graduate degrees. That was probably a large part of it. Also, in my mind, what accounted for such a focus, almost a laser focus, in some regard, for several years on developing the science of
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nursing was because quite frankly, in those days, science was what had the status. If it wasn’t science you didn’t get money for research. No one paid attention in so many ways if it wasn’t science, if it wasn’t data based. In many ways, this wasn’t bad because it did help in the beginning to get the momentum going, but it excluded everything else. Who knows what other people might have done at that time that would have been of value that wasn’t science. So, like most other things in life, it was a blessing but it also had its limitations in that it excluded a lot of other things that may have developed earlier than they did. EE: We’ve talked about who inspired you, you sound very inspired by the humanities and liberal arts . . . . BC: And that’s still very much a part of my life. I think it continues to inform how I live my life. I very much enjoy music. I listen to music a great deal. I have expanded my listening repertoire over the last several years, as well as my reading; I still manage to read quite a bit in a variety of areas—history, cultural and intellectual philosophy, philosophy itself, and I have encountered some biographies. I love biographies; it’s actually fascinating, some of these biographies, like Einstein— I was just fascinated with that one. Some fiction, too, I have found interesting. I always used literature in my teaching because literature and prose, as well as poetry, can distill a certain kind of experience and context that most of us would never experience. And to me, that is then expanding your skills and understanding of other people’s lives, you know, [being] able to interpret how you might respond and what they would find most helpful from you. I have found literature very, very helpful. In fact, I had several phone calls from faculty when I went back to teach at Texas Women’s University. I was teaching in the doctoral program and developed a course in ethics, and one of the required readings in there was Frankenstein!10 EE: Oh. In fact, you write about that in one of your papers, I believe3 . . . .
BC: Yes. I had several phone calls from other universities from the ethics professors. He said, “I’ve heard this, do you really do this?” And I said, “Yes, I do!” And it engaged students because it was interesting, these were doctoral students; almost none of them had read Frankenstein.10 And they couldn’t imagine why I would require that. So, it really got their attention. It worked! EE: I’m sure it did. I find that fascinating. BC: That was one of the joys of teaching that I could have interaction with many more people than I would have had in other circumstances, to get them to stop and think. What does being a nurse mean to you? What do you think you need to know to be a nurse? And it’s not just science and it’s just not the technology. You need to know that, but if you stop at that you will never be a very good nurse.
THEORY AND PRACTICE EE: Some authors consider your patterns of knowing a theory [see, eg, reference #4]. Do you consider that a theory? BC: Absolutely not. EE: No? Okay. Can you talk a little bit about the difference? BC: Well, to me it’s, shall we say a cultural or intellectual philosophy of nursing, not a theory. It was never intended to be that way. It was never an expectation of mine. I was simply, at that point in my life, saying to myself— “What is nursing? What is the practice of nursing? And what is required to be a skillful practitioner?” And a lot of that in my immediate past came out that the way we were teaching nurses in those days it was the science— period—and of course some of the clinical skills. But I think that’s what I was ultimately resisting. I was saying—the science, yes, it is important, but that isn’t nursing, period. EE: Do you feel like your work has been incorporated into curriculums to the fullest extent that it can be? BC: Well, I don’t know. I know certainly it has been incorporated into several curriculums. I’m not in a position to say how
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An Interview With Dr Barbara A. Carper successful they have been in how they have integrated it. Once you publish something it’s a matter of someone else’s interpretation. And how do you go about using it, which is fine, I have no objection. I think one of the things, though, a couple of curriculums I had knowledge of in the past—how they have gone about incorporating it is the art of nursing—which in my mind is the practice— which incorporates all of the other parts. It’s something you can only introduce a student to, because I think to become an effective practitioner and to develop the art of your practice take years and years of conscious attention. Not just years of going to work, but years of looking at your practice, in all aspects. And that’s something that doesn’t just happen by the time you finish an undergraduate program or even for many even when they finish a graduate program. And I think I became very, very conscious of that in terms of what they were attempting in some of these programs in terms of the art. Now I think you have to introduce a student; in a sense, it’s like learning any other art as a beginner. Either painting or learning how to play a musical instrument, you have to begin with the very basics as you do in nursing—the science, the social aspects. The liberal arts, the literature, supporting humanities become critically important later. I think most undergraduate students see that as, “well this is something we have to do because they say we have to do it, but I don’t know what it has to do with nursing,” and that disturbs me because often we don’t make it apparent to them. What does it have to do with nursing? First of all, it has to do with you as a person, as a human being. As a practitioner, you are a very critical element in the environment, in the context, and are very different from the person next to you or the other person next to them or from the patient you are providing care for, and that becomes a very, very important aspect. I think we don’t make that as evident as we might possibly be able to do with an undergraduate because, again, we are trying to educate on so many things and 4 years is not a long time when you look at everything
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that has to be taught, but again you have to begin with the basics. If you are going to learn an instrument you have to learn the notes, you have to learn how to read written music. Then you have to learn the particular instrument and you have to put them together. It’s a matter of integrating everything you’ve learned before into what you’ve learned now and I think a practice is like that too. That’s why, once you take music lessons or if you take art lessons, after 2, or 3, or 4, years you’re not a Rembrandt or a Picasso. Once you finish an undergraduate or even a master’s program, that doesn’t make you a master necessarily. Now some people manage to move faster than others, I think, in terms of developing their own set of artful skills and combinations in their practice. And with others, it takes longer and some, I can testify, never, never get to that point. EE: You must have opinions about the 2 year degree programs. BC: Well, they are really, in terms of what I see as an accomplished and experienced practitioner, they are real beginners, in terms of the practice. For many people, it’s the only opportunity they have to get started. It’s what they do to develop their own practice after that that really counts.
TECHNOLOGY AND THE CURRENT STATE OF NURSING EE: When you wrote “The Ethics of Caring”3 you talked about caring decreasing when technology increases, and I wonder what your perspective is on the current state of affairs in that regard? Do you see that prediction having come true? BC: I do, unfortunately, to a very large extent. The last several years I have spent 24/7 looking after my husband and on several occasions he did require hospitalization. I did get to observe some of the nursing and there was certainly more than 1 nurse—he was in 2 different hospitals, so it wasn’t just a particular environment—with their computers, their portable computers on wheels. They would
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come in the room and would be there maybe 3, or 4, or 5 minutes before they ever looked at him. I would just sit there and observe and say to myself, “I don’t believe this!” Then they would give the medications, or the injections, or check his IV, and that was it, out the door. I was personally, as a nurse, very disturbed about that. I found some of the nurses’ aides much more tuned in to the human being in the bed than the nurses were . . . about being comfortable, making observations, or listening to what he was saying. Particularly in hospitals now very few people actually listen to what the patient is saying. You know, they say, “well we’ve got your medical history.” That disturbs me too—that so very often medical professional people do not listen, do not allow the patient to tell their story, about their illness. You can learn an awful lot by listening to the patient’s story of their illness. In response to your question about technology in medical and nursing practice, it has made an enormous difference. Even going to the doctor’s office, they’re sitting there with their back turned, with their fingers on the keyboard, looking at the computer, with few exceptions, and if that happens more than twice, I find another doctor. Turn around and look at me! Listen to me! EE: Yes. It’s very difficult. Going to the doctor, that was one of my questions for you—in your experience as a patient is nursing care what you think it ought to be? And what I’m hearing is no, it’s not. BC: For the most part it isn’t. But it could be! I have encountered excellent, excellent, what I would call artists in the practice of nursing. For the most part they have been nurse practitioners. I don’t know if that kind of person is attracted to the nurse practitioner program or as a result of their experience and their set of skills they become much a different kind of nurses. They do listen; sometimes they are the only one to listen. They let the patient tell their story. And one of the other things about nurses in hospitals—doctors too, but doctors are
doctors—nurses should be a little more tuned in about what has happened [to the patient] in the hospital. The changes that have been made or the expectations and how are they [patients] going to manage? Are they going to be able to manage? Do they really understand what that means? What will that mean to the patient once they get home? What kind of help will they have? One of the things I accomplished when I came to the University of North Carolina was to negotiate clinical placement at a small hospice in Charlotte for some of the students. I thought that kind of experience, when you are caring for someone you know cannot be cured, what then does nursing practice require? For me, that was an enormous learning experience. The students were self-selected and I thought that would work best, that they would benefit the most from that kind of a practice environment. EE: Yes. So what is your answer to that question? BC: It depends on the context and the person and who you are, because everyone, even when they are dying, dies in their own way. The only easy answer is if they’re unresponsive and unconscious, then it’s clear that it’s about comfort, comfort measures, and then you turn your attention to the family—what do they need? The more I have informed myself in terms of practice and the more experience I acquired—and this is going to sound strange, but—the less able I am to give a direct and simple answer to a question that involves another human being. So I do think [nursing] could be [what it ought to be]. But technology is very alluring, particularly now that some of the younger nurses grew up with it. It’s just part of their lives. It’s kind of like when I saw some of these nurses in the hospital come in and stare at their computer screens for 5 minutes before looking up to see the human being in the bed. It reminded of some of these—well, I say teenagers, but some of them are even younger—that tweet each other when they are in the same room!
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An Interview With Dr Barbara A. Carper EE: Yes. I have a question here about how you feel texting, for example, has affected human relationships because I know a lot of people think that has sorely impacted nursing. BC: This is my personal opinion—I think, and I’m certainly not antitechnology, I think it’s an extremely critical thing, very important in many regard, but as far as substituting e-mail and texting [for face-to-face communication] if that constitutes 90% of your communication with other human beings, I think that has an enormous impact because “the other” becomes a faceless entity. And yes, particularly when you start doing that when you are 12 years old, I think that has an enormous impact on how children that age growing up in terms of how they relate to other people and the skills they develop in relating to other people or that they don’t develop in relating to other people, I’ll put it that way. EE: What is your vision for nursing at this point? BC: Learning to nurse in a totally different environment and context is one of the things I think is a challenge to nursing today. How to incorporate and utilize existing and yet [to be] invented technologies without losing the critical elements of the practice; without forgetting that the end point for all of this is a human being, a patient. The technology doesn’t exist in and for itself. It’s a tool to use in the assistance, diagnosis, treatment, and the support of a human being. EE: So it sounds to me like, instead of staring at the computer screen, you’d like someone to come in and look someone in the eye and greet them and listen to their story and go from there. BC: Well, yes. What I’m saying is, they should do it all! Don’t get rid of the computer, definitely not, but just incorporate into the context so that it becomes one piece of the furniture, so to speak; one of the aids or tools. One of the things I find very interesting is that computers were supposed to be time saving. I don’t find that. My experience has been exactly the opposite. In fact, so time consuming
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that about 6 months ago I unplugged my computer! If I really, really need one, if it would make a big difference, I go to the library and use theirs.
CONTRIBUTION EE: Your paper “Fundamental Patterns of Knowing in Nursing”1 has been cited over 1800 times according to Google Scholar as of yesterday.2 BC: My goodness! EE: I don’t know if you are aware of that, but it’s phenomenal. So talk to me about what you feel is your most enduring contribution to nursing science at this point. BC: I would say my major contribution was not just to nursing science but was to the practice of nursing, and that contribution was to get nurses, and those who taught nurses, to think about something more than the science, in terms of what is the practice of nursing. That was always my end point, the practice. When you make the practice of your profession the focus, then that informs everything else. It informs the science—okay, given this practice, what do we need to be doing research about? Not the other way around. Not, “we are doing this research” then “how do we change the practice to fit it?” To me that’s the wrong way around. EE: Do you have any other comments about the patterns of knowing or your other scholarly work? BC: Regarding the patterns of knowing, I was surprised and gratified that it received the attention that it did. I had certainty not expected that! I thought it would disappear into the archives and accumulate dust like so many dissertations do. I think one reason for the attention is that it demonstrated that we are not limited to one kind of knowledge or way of knowing. I think that resonated with experienced clinicians in their practice, but it probably wasn’t discussed much. They agreed that we do require different kinds of knowing . . . all of value but different ways . . . it’s not “either or,” but all of them.
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EE: Talking to you certainly is fascinating, Dr Carper. I think there are an awful lot of people who would like to know something
about you and I think your point of view is still very relevant and very important. Thank you for allowing me to do this interview.
REFERENCES 1. Carper BA. Fundamental patterns of knowing in nursing. Adv Nurs Sci. 1978;1(1):13-24. 2. Google Scholar. http://scholar.google.com/. Accessed July 27, 2014. 3. Carper BA. The ethics of caring. Adv Nurs Sci. 1979;1(3):11-20. 4. Fawcett J, Watson J, Neuman B, Walker PH, Fitzpatrick JJ. On nursing theories and evidence. J Nurs Scholarsh. 2001;33(2):115-119. 5. Hart CW. Biography as an art form: the story of Helen Flanders Dunbar, M.D., Ph.D., B.D., and Med. Sci. D. J Relig Health. 2014;53(3):778-788. 6. Carper BA. Fundamental Patterns of Knowing in Nursing. [EdD dissertation]. New York, NY:
7. 8. 9.
10.
Columbia University Teachers College; 1975:176. http://pocketknowledge.tc.columbia.edu/home. php. Accessed October 13, 2014. Phenix PH. Realms of Meaning. New York, NY: McGraw Hill; 1964. Mishler EG. Meaning in context: is there any other kind? Harv Educ Rev. 1979;49(1):1-19. Benner P. From Novice to Expert: Promoting Excellence and Career Development in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984. Shelley MW. Frankenstein; or, The Modern Prometheus. London, England: Lackington, Hughes, Harding, Mavor, & Jones; 1818.
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Advances in Nursing Science Vol. 38, No. 2, pp. 73–82 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
An Interview With Dr Barbara A. Carper Elizabeth R. Eisenhauer, RN, BSN, MLS In 1978, Dr Barbara A. Carper’s foundational work, “Fundamental Patterns of Knowing in Nursing,” arguably created a paradigm shift in nursing. However, her voice has been absent from the nursing literature in recent years. I was privileged to conduct a personal interview with Dr Carper in 2014. The edited interview includes a synopsis of her background, career trajectory, sources of inspiration, and her perspective on the current state of nursing. She reaffirmed her passion for reflective nursing practice, the importance incorporating the arts and humanities into nursing education, and using an integrated approach with the patterns of knowing in nursing. Key words: caring, Carper, epistemology, nursing practice, nursing theory, patterns of knowing, technology, ways of knowing
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N 1978, Dr Barbara Carper’s foundational work “Fundamental Patterns of Knowing in Nursing”1 appeared in Advances in Nursing Science and has subsequently been cited more than 1800 times in the professional literature.2 This highly influential work and other publications of Dr Carper’s such as “The Ethics of Caring”3 are so substantially related to my research on bioethics and informed consent that I became inspired to, or maybe obsessed with, investigating her cur-
Author Affiliation: School of Nursing, University of Michigan, Ann Arbor. The author has no conflicts of interest to declare. Funding: No funding was received specifically for this research. Elizabeth Eisenhauer is a recipient of the 2014-2016 Jonas Nurse Leader Scholar Award. The author thanks Dr Barbara A. Carper for allowing this interview; Dr Lienne D. Edwards for her assistance in contacting Dr Carper; Dr Cynthia ArslanianEngoren for being an excellent mentor and confidant; Dr Jacqueline Fawcett for her inspirational examples of interviews with the Nurse Theorists; and 3 anonymous reviewers for their helpful comments. Correspondence: Elizabeth R. Eisenhauer, RN, BSN, MLS, School of Nursing, University of Michigan, 400 North Ingalls, Ann Arbor, MI 48109 ([email protected]). DOI: 10.1097/ANS.0000000000000067
rent status. After some research and correspondence by mail, I was granted the privilege of a telephone interview with Dr Carper on July 28, 2014, and a personal meeting with her on August 25, 2014. This is an edited version, mostly from the telephone interview. Dr Carper was given the opportunity to make editorial changes prior to submission for publication. Final contributions were received, via telephone, from Dr Carper on February 17, 2015. Although Dr Carper initially described herself to me as a very “private person,” she was gracious enough to share some of her life story. Biographical information can be seen as an example of personal, aesthetic, and even ethical ways of knowing.4,5 In the interview, Dr Carper also reaffirmed her passion for reflective nursing practice, the importance incorporating the arts and humanities into nursing education, and using an integrated approach with the patterns of knowing in nursing. Not intended to be a theoretical or philosophical analysis of the patterns of knowing, the aim of the interview was to learn about Dr Carper’s background, career, and perspective on the current state of nursing. A follow-up manuscript, a scholarly analysis on how the patterns of knowing and Carper’s other work relate to research on informed consent and decision making, is in preparation. 73
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BACKGROUND EE: First of all let me thank you again for agreeing to do this interview. Your work is very well known and very influential and I’m sure will continue to be forever. Basically, there are 3 topics I would like to cover with you—your background, your career, and your perspective on the current state of nursing science. Could you please tell me a little bit about how you grew up or where you are from? BC: I grew up in Texas and Oklahoma during the 1940s and 1950s. I was raised by my grandparents for the most part. I couldn’t have asked for a better family. I had a large extended family so I was always surrounded by cousins and aunts and uncles. There was always someone to pick me up when I was a kid if I fell and scrapped my knee, or tell me not to do this or that! EE: What do you remember about deciding to become a nurse? BC: I think I was probably in high school and thinking about going to college. You know in the early 1950s it was a very different environment for women. Most people then thought that there were only a few choices that would be suitable for a woman. In those days, it would be extremely rare and maybe in some circumstances even impossible if a woman wanted to become an engineer or as physicist. My grandfather was absolutely wonderful. First of all, when I was in high school he made me take typing. He said a woman could always get a job typing, meaning a secretary or receptionist or something like that if she couldn’t get any other job. My grandmother had been a nurse during the late 1920s and 1930s. Of course, her background was very, very different. In those days, particularly where she grew up in Texas, you learned to become a nurse by being an apprentice to a physician. I remember that because during the second World War there was a real nursing shortage. So many nurses went into the military that she went back to work in a doctor’s office during the 1940s because he couldn’t find anyone to help. So she probably had an influence on me. She was also someone
prominent in the community. If someone had a sick child they would call her and she would go over and take a look and tell them if they needed to go to a doctor. Going to a doctor in those days wasn’t something people did unless they thought it was a very bad situation. Now people go if they have a runny nose and a cough. I think probably just seeing what she did and how she responded and how people responded to her; she was a very, very important person to that community. She was the person they relied on for advice or for help and I’m sure that had an influence on me. But I decided I wanted to be a nurse and of course in those days the usual route was the hospital program, but I said, “No, I want to go to college.” I didn’t want to just be a nurse. I loved literature and music; in fact that was what I really wanted to do in college, was major in music but my grandfather said, “Absolutely not!” He said, “You can’t make a living being a musician.” Of course in those days the expectation was—it doesn’t really matter about going to college because women were expected to get married and their husbands would provide. This was his expectation, too, but he said, “What if something happened to your husband and you had a family? At least you’d be able to do something.” At least he was thinking forward that much. So, I insisted that I wanted to be a nurse but I wanted to go to college. I could do both. EE: That’s excellent. That’s a fascinating story. I think a lot of that goes on today too— parents pushing children in career directions as opposed to any kind of art or liberal arts. BC: Oh, yes. I think it’s even more prominent today, in a sense, because we are such a technology-focused culture that they don’t see any point in the humanities for the most part.
CAREER EE: Please tell me about the trajectory of your career. BC: I went to college at Texas Women’s University. I graduated in 1959. We just had
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An Interview With Dr Barbara A. Carper our 55th class reunion. The College of Nursing there was 1 of the very earliest 4-year programs in Texas. I think I was in either the first or second class. I deliberately chose Texas Women’s University because I wanted to go to a women’s college. In the 1950s that was sort of against the grain. Most people my age after high school wanted to go to the larger coed university but I just thought there would be more opportunity at a women’s college to make choices that you might not otherwise have made; to concentrate on what you were really interested in and I was able to take advantage of some of those things—the music, some of the athletics, however, limited because the nursing program was extremely time consuming. We went 12, well 11 months a year, for 4 years. Then I did some clinical nursing and from my experience there I became very interested in being a nurse anesthetist. So I did go to the University of Michigan, to the Medical School there in Ann Arbor. It was either an 18-month or a 2-year program certification (in those days, it wasn’t a degree program but a certification program) and finished there and took my certifying exams as a nurse anesthetist. I did that for quite a few years and I liked it very much, but quite frankly, after several years I missed the patient contact. You had very brief contact, you spent hours with them but they were unconscious and then they were gone. I always wondered, “how did they do?” “What happened to them after we took them out of the recovery room?” So I decided then to go back and get a master’s degree. I went to Teachers College at Columbia University in New York and obtained my master’s degree. Then I went from New York to New Mexico to teach! Well, I wanted to see something different. I loved New York. I just took to Manhattan like a duck to water but thought I’d try something different. EE: And then did you teach in Texas? BC: Yes, after I finished my doctorate I went back to Texas Women’s University to the faculty there. By then it was quite a large program; they had not only the program on the main campus, which was in Denton few
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miles north of Dallas, but they had a clinical campus in Dallas and a clinical campus in Houston. They had expanded tremendously since I had graduated. I was there for quite some time. My last position there, I was a director of their PhD program. EE: And then you went to New Hampshire after that? BC: Yes, my husband and I decided to make that move for family reasons. We moved to a small town in New Hampshire and for the first 2 years we were there I commuted to Maine—to Portland—the University of Southern Maine. Two very good friends of mine (we had been classmates at Columbia), one was the dean [Audrey Conley] and one was the associate dean [Carla Mariano], somehow or other persuaded me to make that commute every week from New Hampshire to Maine. The University of Southern Maine had a fairly young graduate program, a master’s degree program, and so I went there for 2 years to be director of the graduate program—the master’s degree program—and particularly enjoyed it, but the commute particularly in New Hampshire winters was stressful. I decided the commuting was too much. There was a small, private, liberal arts college Colby-Sawyer in the town where I was living—New London, New Hampshire. They had just started a nursing program—I think it was 2 years previously—and the person who had started that program was resigning. So I took that job. That was almost building it from the ground up. They hadn’t even gotten to the point where they’d gotten the state board of nursing approval so that was an enormous challenge and extremely time consuming, but it was a wonderful setting! Nursing in the middle of this liberal arts college was [something] they didn’t quite understand. So I set about making connections with the liberal arts people, the humanities people, and they were a wonderful group of people and very soon I felt at home and at place there. And the nursing faculty! If I had hand-picked them I could not have gotten a better group. So that was a wonderful experience, working with all of those people, the nursing faculty
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and people particularly in the sciences that were so critically important for the nursing program. I was there until ‘89. Once our daughter finished college, again, for personal reasons, my husband and I decided to go further south and after some exploration and looking around— we came to the University of North Carolina at Charlotte, which had a very good undergraduate program and had, a few years before, established a graduate program master’s degree. They needed some experienced faculty and I saw a wonderful opportunity! I love to go into programs that are growing and changing rather than those that have reached the point where they think they are perfect and nothing needs to be altered. So, again, this was just like me going to New Mexico, when I came to the University of North Carolina at Charlotte, and I stayed there until I retired in 1999.
INSPIRATION AND INFLUENCE EE: It is fascinating to hear about you, Dr Carper. The fact that you were working with unconscious patients, I wonder how you think that influenced the “patterns of knowing”? BC: Well, I’d never thought about it that way. I could say, certainly, spending so many hours with an unconscious patient constantly monitoring and caring for in a way but without any communication between us, it probably did lead to why I decided to go back [to school]. That was for me a very important missing link—the patient. I decided it really was important enough to do something differently. As I said, I enjoyed the nursing; being a nurse anesthetist, it was also very demanding but again, it was just that missing link. I wanted to be conscious and present with another conscious and present human being who I was caring for. EE: So what do you think inspired you to write about the “ways of knowing”? BC: It was at the University of New Mexico, when I was teaching there [mid to late 1960s]
that I became aware of some of the personal concerns I had about what the curriculum focused on, what we went about emphasizing, and in some aspects what we ignored or paid little attention to or placed little importance on from a practice perspective. Science, and the science of nursing, had become the focus at that point in time. I think it would be a bit of an exaggeration to say that there was such a strong focus on the science that there was an exclusion of everything else, but science, the science of nursing, became “the elephant in the room.” But in my mind everything that surrounded nursing, that I thought was important to the practice of nursing, seemed to have become less important to the students, almost to the point where they thought, “it doesn’t count” or “if I don’t have time for that it doesn’t matter” and that bothered me very much because I thought there was more to nursing practice than the way we were approaching it at that point in time. After a while, I decided, “there is something missing here I would like to explore some more.” So that’s when I decided to go back and get my doctorate from Columbia, again, Teachers College, Columbia. EE: You mentioned something was “missing.” What was missing? Can you please provide an example? BC: A lack of consideration of ethics was missing from both education and practice. There was no real time devoted to the teaching of ethics. In nursing education, ethics was frequently restricted to teaching the Nightingale pledge. It was more rule-oriented than principle-oriented, in terms of the morality of [one’s] actions. Very few people were prepared to address ethics at that time. But there were very real, ethical, and moral concerns that I observed in practice. For example, it was common, accepted practice—not fully informing patients about their condition or their treatment. Information was frequently omitted. I can recall several instances of patients not being informed that they had a terminal illness, and their families were not informed either! That was very disturbing to me, and it wasn’t just a few
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An Interview With Dr Barbara A. Carper patients, that was the standard at the time. Most health care workers at that time did not see it as an ethical issue. Of course, clinicians varied; some provided more information than others. Some providers omitted information that would have been very important about making choices in terms of treatment. So, for me, developing the patterns of knowing was a response to intellectual and personal concerns to clarify and express that nursing practice was more than science; nursing practice was not limited to that. EE: Did other fields or theorists impact or influence your work? BC: In college, I became interested in philosophy and I did a considerable amount of reading just because I liked it. And over time, history, too, became something I very much enjoyed reading and learning about. I don’t mean dates, but intellectual history, cultural history, and there were some professors at Columbia who influenced me. I took more courses than I had to because it intrigued me. I took some philosophy courses, and at the time there was a wonderful professor of philosophy who did, I think, enormously influence me in my dissertation6 —Phil Phenix.7 He’s deceased now but I took his course, which probably had a major influence on what I decided I was going to do with my dissertation.6 There was another professor at Columbia that taught a course in cultural history, which I thoroughly enjoyed. I took 2 or 3 philosophy courses at Columbia and enjoyed every one of them. I particularly remember Dr Phenix.7 History reinforced the notion in my mind of context, how important context is. One professor that I took a course from wrote an article called “Meaning in Context: Is there any other kind?”8 And that really made me stop and think because, of course, there really isn’t, particularly when you are talking about relationships with human communication. Anything in which one has to relate to another, context becomes critically important. But context is also important in science. You don’t disregard the context in terms of interpreting the data.
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So, yes there have been a lot of people and books and ideas that have influenced me— that, as we all do, I just sort of . . . I thought about them sometimes over a period of several years, and it became incorporated in my perspective without stopping to cite the source, so to speak. There were several people too, after I wrote my dissertation. There have been some people, too, writing independently of me but I think they were very often on the same track. One of them in nursing is Pat Benner. When I read her book9 I thought, “Oh she got it. She got it!” EE: Yes. I was wondering what other nursing theorists you favor. You were a contemporary of people like Watson and Leininger. Did they influence your work at all or did you know each other? BC: Oh, yes in fact in the early days most of us knew each other! It was a small group so most of us knew each other one way or the other. And it was amazing . . . some of the discussions we’d have. You know, we’d go to a conference or a meeting and there’d always be some of the others there and the conversations we’d have over the dinner table! Yes, yes. Peggy Chinn and I were colleagues for quite some time. She is one of those people that we could, you know, sit down over lunch or whatever and have the most wonderful conversations! EE: I often think your views are much in line with Dr Peplau’s work. BC: Oh, yes, I knew her. Not as well as I knew some of the others but she was a remarkable woman. In fact they all were; we were all remarkable in our day and time! The whole army of us! EE: I’m sure that was fascinating. What do you think was going on in the late 1970s or early 1980s that generated so much new nursing theory at the time? BC: This was when nurses started getting interested in going back for graduate degrees. That was probably a large part of it. Also, in my mind, what accounted for such a focus, almost a laser focus, in some regard, for several years on developing the science of
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nursing was because quite frankly, in those days, science was what had the status. If it wasn’t science you didn’t get money for research. No one paid attention in so many ways if it wasn’t science, if it wasn’t data based. In many ways, this wasn’t bad because it did help in the beginning to get the momentum going, but it excluded everything else. Who knows what other people might have done at that time that would have been of value that wasn’t science. So, like most other things in life, it was a blessing but it also had its limitations in that it excluded a lot of other things that may have developed earlier than they did. EE: We’ve talked about who inspired you, you sound very inspired by the humanities and liberal arts . . . . BC: And that’s still very much a part of my life. I think it continues to inform how I live my life. I very much enjoy music. I listen to music a great deal. I have expanded my listening repertoire over the last several years, as well as my reading; I still manage to read quite a bit in a variety of areas—history, cultural and intellectual philosophy, philosophy itself, and I have encountered some biographies. I love biographies; it’s actually fascinating, some of these biographies, like Einstein— I was just fascinated with that one. Some fiction, too, I have found interesting. I always used literature in my teaching because literature and prose, as well as poetry, can distill a certain kind of experience and context that most of us would never experience. And to me, that is then expanding your skills and understanding of other people’s lives, you know, [being] able to interpret how you might respond and what they would find most helpful from you. I have found literature very, very helpful. In fact, I had several phone calls from faculty when I went back to teach at Texas Women’s University. I was teaching in the doctoral program and developed a course in ethics, and one of the required readings in there was Frankenstein!10 EE: Oh. In fact, you write about that in one of your papers, I believe3 . . . .
BC: Yes. I had several phone calls from other universities from the ethics professors. He said, “I’ve heard this, do you really do this?” And I said, “Yes, I do!” And it engaged students because it was interesting, these were doctoral students; almost none of them had read Frankenstein.10 And they couldn’t imagine why I would require that. So, it really got their attention. It worked! EE: I’m sure it did. I find that fascinating. BC: That was one of the joys of teaching that I could have interaction with many more people than I would have had in other circumstances, to get them to stop and think. What does being a nurse mean to you? What do you think you need to know to be a nurse? And it’s not just science and it’s just not the technology. You need to know that, but if you stop at that you will never be a very good nurse.
THEORY AND PRACTICE EE: Some authors consider your patterns of knowing a theory [see, eg, reference #4]. Do you consider that a theory? BC: Absolutely not. EE: No? Okay. Can you talk a little bit about the difference? BC: Well, to me it’s, shall we say a cultural or intellectual philosophy of nursing, not a theory. It was never intended to be that way. It was never an expectation of mine. I was simply, at that point in my life, saying to myself— “What is nursing? What is the practice of nursing? And what is required to be a skillful practitioner?” And a lot of that in my immediate past came out that the way we were teaching nurses in those days it was the science— period—and of course some of the clinical skills. But I think that’s what I was ultimately resisting. I was saying—the science, yes, it is important, but that isn’t nursing, period. EE: Do you feel like your work has been incorporated into curriculums to the fullest extent that it can be? BC: Well, I don’t know. I know certainly it has been incorporated into several curriculums. I’m not in a position to say how
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An Interview With Dr Barbara A. Carper successful they have been in how they have integrated it. Once you publish something it’s a matter of someone else’s interpretation. And how do you go about using it, which is fine, I have no objection. I think one of the things, though, a couple of curriculums I had knowledge of in the past—how they have gone about incorporating it is the art of nursing—which in my mind is the practice— which incorporates all of the other parts. It’s something you can only introduce a student to, because I think to become an effective practitioner and to develop the art of your practice take years and years of conscious attention. Not just years of going to work, but years of looking at your practice, in all aspects. And that’s something that doesn’t just happen by the time you finish an undergraduate program or even for many even when they finish a graduate program. And I think I became very, very conscious of that in terms of what they were attempting in some of these programs in terms of the art. Now I think you have to introduce a student; in a sense, it’s like learning any other art as a beginner. Either painting or learning how to play a musical instrument, you have to begin with the very basics as you do in nursing—the science, the social aspects. The liberal arts, the literature, supporting humanities become critically important later. I think most undergraduate students see that as, “well this is something we have to do because they say we have to do it, but I don’t know what it has to do with nursing,” and that disturbs me because often we don’t make it apparent to them. What does it have to do with nursing? First of all, it has to do with you as a person, as a human being. As a practitioner, you are a very critical element in the environment, in the context, and are very different from the person next to you or the other person next to them or from the patient you are providing care for, and that becomes a very, very important aspect. I think we don’t make that as evident as we might possibly be able to do with an undergraduate because, again, we are trying to educate on so many things and 4 years is not a long time when you look at everything
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that has to be taught, but again you have to begin with the basics. If you are going to learn an instrument you have to learn the notes, you have to learn how to read written music. Then you have to learn the particular instrument and you have to put them together. It’s a matter of integrating everything you’ve learned before into what you’ve learned now and I think a practice is like that too. That’s why, once you take music lessons or if you take art lessons, after 2, or 3, or 4, years you’re not a Rembrandt or a Picasso. Once you finish an undergraduate or even a master’s program, that doesn’t make you a master necessarily. Now some people manage to move faster than others, I think, in terms of developing their own set of artful skills and combinations in their practice. And with others, it takes longer and some, I can testify, never, never get to that point. EE: You must have opinions about the 2 year degree programs. BC: Well, they are really, in terms of what I see as an accomplished and experienced practitioner, they are real beginners, in terms of the practice. For many people, it’s the only opportunity they have to get started. It’s what they do to develop their own practice after that that really counts.
TECHNOLOGY AND THE CURRENT STATE OF NURSING EE: When you wrote “The Ethics of Caring”3 you talked about caring decreasing when technology increases, and I wonder what your perspective is on the current state of affairs in that regard? Do you see that prediction having come true? BC: I do, unfortunately, to a very large extent. The last several years I have spent 24/7 looking after my husband and on several occasions he did require hospitalization. I did get to observe some of the nursing and there was certainly more than 1 nurse—he was in 2 different hospitals, so it wasn’t just a particular environment—with their computers, their portable computers on wheels. They would
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come in the room and would be there maybe 3, or 4, or 5 minutes before they ever looked at him. I would just sit there and observe and say to myself, “I don’t believe this!” Then they would give the medications, or the injections, or check his IV, and that was it, out the door. I was personally, as a nurse, very disturbed about that. I found some of the nurses’ aides much more tuned in to the human being in the bed than the nurses were . . . about being comfortable, making observations, or listening to what he was saying. Particularly in hospitals now very few people actually listen to what the patient is saying. You know, they say, “well we’ve got your medical history.” That disturbs me too—that so very often medical professional people do not listen, do not allow the patient to tell their story, about their illness. You can learn an awful lot by listening to the patient’s story of their illness. In response to your question about technology in medical and nursing practice, it has made an enormous difference. Even going to the doctor’s office, they’re sitting there with their back turned, with their fingers on the keyboard, looking at the computer, with few exceptions, and if that happens more than twice, I find another doctor. Turn around and look at me! Listen to me! EE: Yes. It’s very difficult. Going to the doctor, that was one of my questions for you—in your experience as a patient is nursing care what you think it ought to be? And what I’m hearing is no, it’s not. BC: For the most part it isn’t. But it could be! I have encountered excellent, excellent, what I would call artists in the practice of nursing. For the most part they have been nurse practitioners. I don’t know if that kind of person is attracted to the nurse practitioner program or as a result of their experience and their set of skills they become much a different kind of nurses. They do listen; sometimes they are the only one to listen. They let the patient tell their story. And one of the other things about nurses in hospitals—doctors too, but doctors are
doctors—nurses should be a little more tuned in about what has happened [to the patient] in the hospital. The changes that have been made or the expectations and how are they [patients] going to manage? Are they going to be able to manage? Do they really understand what that means? What will that mean to the patient once they get home? What kind of help will they have? One of the things I accomplished when I came to the University of North Carolina was to negotiate clinical placement at a small hospice in Charlotte for some of the students. I thought that kind of experience, when you are caring for someone you know cannot be cured, what then does nursing practice require? For me, that was an enormous learning experience. The students were self-selected and I thought that would work best, that they would benefit the most from that kind of a practice environment. EE: Yes. So what is your answer to that question? BC: It depends on the context and the person and who you are, because everyone, even when they are dying, dies in their own way. The only easy answer is if they’re unresponsive and unconscious, then it’s clear that it’s about comfort, comfort measures, and then you turn your attention to the family—what do they need? The more I have informed myself in terms of practice and the more experience I acquired—and this is going to sound strange, but—the less able I am to give a direct and simple answer to a question that involves another human being. So I do think [nursing] could be [what it ought to be]. But technology is very alluring, particularly now that some of the younger nurses grew up with it. It’s just part of their lives. It’s kind of like when I saw some of these nurses in the hospital come in and stare at their computer screens for 5 minutes before looking up to see the human being in the bed. It reminded of some of these—well, I say teenagers, but some of them are even younger—that tweet each other when they are in the same room!
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An Interview With Dr Barbara A. Carper EE: Yes. I have a question here about how you feel texting, for example, has affected human relationships because I know a lot of people think that has sorely impacted nursing. BC: This is my personal opinion—I think, and I’m certainly not antitechnology, I think it’s an extremely critical thing, very important in many regard, but as far as substituting e-mail and texting [for face-to-face communication] if that constitutes 90% of your communication with other human beings, I think that has an enormous impact because “the other” becomes a faceless entity. And yes, particularly when you start doing that when you are 12 years old, I think that has an enormous impact on how children that age growing up in terms of how they relate to other people and the skills they develop in relating to other people or that they don’t develop in relating to other people, I’ll put it that way. EE: What is your vision for nursing at this point? BC: Learning to nurse in a totally different environment and context is one of the things I think is a challenge to nursing today. How to incorporate and utilize existing and yet [to be] invented technologies without losing the critical elements of the practice; without forgetting that the end point for all of this is a human being, a patient. The technology doesn’t exist in and for itself. It’s a tool to use in the assistance, diagnosis, treatment, and the support of a human being. EE: So it sounds to me like, instead of staring at the computer screen, you’d like someone to come in and look someone in the eye and greet them and listen to their story and go from there. BC: Well, yes. What I’m saying is, they should do it all! Don’t get rid of the computer, definitely not, but just incorporate into the context so that it becomes one piece of the furniture, so to speak; one of the aids or tools. One of the things I find very interesting is that computers were supposed to be time saving. I don’t find that. My experience has been exactly the opposite. In fact, so time consuming
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that about 6 months ago I unplugged my computer! If I really, really need one, if it would make a big difference, I go to the library and use theirs.
CONTRIBUTION EE: Your paper “Fundamental Patterns of Knowing in Nursing”1 has been cited over 1800 times according to Google Scholar as of yesterday.2 BC: My goodness! EE: I don’t know if you are aware of that, but it’s phenomenal. So talk to me about what you feel is your most enduring contribution to nursing science at this point. BC: I would say my major contribution was not just to nursing science but was to the practice of nursing, and that contribution was to get nurses, and those who taught nurses, to think about something more than the science, in terms of what is the practice of nursing. That was always my end point, the practice. When you make the practice of your profession the focus, then that informs everything else. It informs the science—okay, given this practice, what do we need to be doing research about? Not the other way around. Not, “we are doing this research” then “how do we change the practice to fit it?” To me that’s the wrong way around. EE: Do you have any other comments about the patterns of knowing or your other scholarly work? BC: Regarding the patterns of knowing, I was surprised and gratified that it received the attention that it did. I had certainty not expected that! I thought it would disappear into the archives and accumulate dust like so many dissertations do. I think one reason for the attention is that it demonstrated that we are not limited to one kind of knowledge or way of knowing. I think that resonated with experienced clinicians in their practice, but it probably wasn’t discussed much. They agreed that we do require different kinds of knowing . . . all of value but different ways . . . it’s not “either or,” but all of them.
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EE: Talking to you certainly is fascinating, Dr Carper. I think there are an awful lot of people who would like to know something
about you and I think your point of view is still very relevant and very important. Thank you for allowing me to do this interview.
REFERENCES 1. Carper BA. Fundamental patterns of knowing in nursing. Adv Nurs Sci. 1978;1(1):13-24. 2. Google Scholar. http://scholar.google.com/. Accessed July 27, 2014. 3. Carper BA. The ethics of caring. Adv Nurs Sci. 1979;1(3):11-20. 4. Fawcett J, Watson J, Neuman B, Walker PH, Fitzpatrick JJ. On nursing theories and evidence. J Nurs Scholarsh. 2001;33(2):115-119. 5. Hart CW. Biography as an art form: the story of Helen Flanders Dunbar, M.D., Ph.D., B.D., and Med. Sci. D. J Relig Health. 2014;53(3):778-788. 6. Carper BA. Fundamental Patterns of Knowing in Nursing. [EdD dissertation]. New York, NY:
7. 8. 9.
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Columbia University Teachers College; 1975:176. http://pocketknowledge.tc.columbia.edu/home. php. Accessed October 13, 2014. Phenix PH. Realms of Meaning. New York, NY: McGraw Hill; 1964. Mishler EG. Meaning in context: is there any other kind? Harv Educ Rev. 1979;49(1):1-19. Benner P. From Novice to Expert: Promoting Excellence and Career Development in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984. Shelley MW. Frankenstein; or, The Modern Prometheus. London, England: Lackington, Hughes, Harding, Mavor, & Jones; 1818.
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