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THEORETICAL PAPER
Knowing in nursing: a concept analysis
Susan A. Bonis
Accepted for publication 12 December 2008
Correspondence to S.A. Bonis:
e-mail: bonis@nursing.umass.edu
Susan A. Bonis MSN RN
Nursing Doctoral Student
School of Nursing, University of
Massachusetts-Amherst, USA
Introduction
The aim of this paper is to analyse the evolution of the
concept of knowing in nursing. Concepts are linguistic
representations of experiential description. They represent a
certain perspective through which an experience is viewed
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JOURNAL OF ADVANCED NURSING
B O N I S S . A . ( 2 0 0 9 ) Knowing in nursing: a concept analysis. Journal of Advanced
Nursing 65(6), 1328–1341.
doi: 10.1111/j.1365-2648.2008.04951.x
Abstract
Title. Knowing in nursing: a concept analysis.
Aim. This paper is a report of an analysis of the evolution of the concept of
knowing in nursing.
Background. Following the seminal contribution of Carper in 1978, knowing has
been discussed with increasing frequency in the nursing literature with reference to
the development of nursing knowledge. Various patterns of knowing, as well as
research focused on reflection on experience, have been the foundation for activities
and research designed to improve practice as well as patient care in clinical, com-
munity, education, cultural and administrative settings.
Methods. Rodgers’ evolutionary method of concept analysis provided the frame-
work for this analysis. The data source was a search of literature published from
1978 to 2007. Three aims guided the analysis: to understand how the concept of
knowing is used in nursing, how it is used in other health-related disciplines and
how the concept has evolved into the current interpretation.
Discussion. Analysis revealed that knowing in nursing refers to a uniquely personal
type of knowledge constructed of objective knowledge interfaced with the individ-
ual’s subjective perspective on personal experience. Knowing is a dynamic process
and a result of personal reflection and transformation as the individual lives and
interacts in the world. Its antecedents are experience, awareness and reflection. The
consequences are understanding, finding meaning and transformation.
Conclusion. This analysis illuminates an area in which nursing has carved out its
own niche in healthcare research. The concept of knowing in nursing practice and
research reflects a focus on the individual experience of health and illness.
Keywords: awareness, concept analysis, experience, knowing, knowledge, nursing,
reflection
and described (Wilson 1983) and therefore represent a type of
knowledge specific to the perspective of a discipline. The
manner in which a concept is used underpins and
guides knowledge development through research, theory
development and application to practice (Chinn & Jacobs
1978).
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JAN: THEORETICAL PAPER
Significant contributions have been made toward develop-
ment and clarification of nursing knowledge since the
introduction of Carper’s (1978) seminal article describing
four patterns of knowing in nursing: empirical knowing,
aesthetic knowing, ethical knowing and personal knowing.
These patterns of knowing have been the foundation of
discussion to further nursing knowledge (Chinn & Jacobs
1978, Moch 1990, Chinn & Kramer 1999, 2004, 2007).
In addition, incorporation of the term ‘knowing’ into the
nursing literature has contributed toward a gradual evolution
of the manner in which the concept of knowing has been used
in the discipline. Various patterns of knowing, as well as
research focused on reflection on experience, have been the
foundation for activities and research designed to improve
practice as well as patient care in clinical, community,
education, cultural and administrative settings. For example,
sociopolitical (White 1995, Heath 1997) and emancipatory
(Chinn & Kramer 2007) patterns of knowing have been
offered as suggestions to explore ontological questions of
being, and unknowing has been suggested as a pattern to
promote a more dynamic process of knowledge development
(Munhall 1993, Heath 1997). Although knowing has
appeared with increasing frequency in the nursing literature,
concept analysis has not yet been used to identify the
attributes, antecedents and consequences of the concept.
Background
The ontological assumption that underpins this analysis is
that knowledge is of two types. One type is objective
knowledge that is logically constructed. The second type is
subjective knowledge that is inductively constructed
through reason (Hume 1740/1993, Kant 1781;1787/2001).
Subjective knowledge is shaped through an individual’s
personal engagement with the environment, or personal
experience. This subjective type of knowledge gained
through personal experience is affected by how the
individual perceives those experiences (Berkeley 1710,
Hume 1740/1993). Chinn and Kramer (1999) refer to this
subjective type of knowledge as knowing, or a way of
‘perceiving and understanding the self and world’ (Chinn &
Kramer 1999, p. 1). Each new experience affects how the
individual perceives future experiences and perceives the
world. Therefore, subjective knowledge is in a continual
process of change through each new experience that is
encountered (Locke 1690/2007).
The ontological foundation of nursing is currently grounded
in this personal type of knowledge from an epistemological
focus on health and illness. This subjective interest in health
and illness has occurred through a gradual shift from an
 2009 The Author. Journal compilation  2009 Blackwell Publishing Ltd
Concept analysis: knowing
empirical focus on disease processes to an embrace of the
human experience, therefore shifting the ontology from one of
empiricism to one of subjective reality. Nursing has evolved
toward using the term knowing to refer to this type of
knowledge that evolves through personal experience.
Rodgers’ evolutionary method of concept analysis is a
method that realizes the uses of concepts evolve and change
over time according to how they are used within a discipline
(Rodgers & Knafl 2000). Literature that is gathered from
over a period of time is examined to determine how the
concept has evolved and what the current use is. Under-
standing how a concept has changed over time, as well as its
current use both inside and outside of nursing, is necessary
for understanding the particular type of knowledge that the
concept implies.
For this reason, Rodgers’ evolutionary method (Rodgers &
Knafl 2000) was used for this analysis. The activities involved
in Rodgers’ method of data collection and analysis occur
simultaneously and iteratively and are: (a) identify the concept
of interest and surrogate terms, (b) identify and select a sample
for gathering data, (c) identify attributes, antecedents and
consequences, (d) analyse data according to the characteristics
of the concept, (e) identify an exemplar and (f) identify
implications for further study (Rodgers & Knafl 2000).
Data sources
The search term ‘knowing’ was entered into CINAHL and
the multidisciplinary database PubMed, resulting in 6562
papers. A more manageable sample was achieved by adding
the search terms ‘personal’ and ‘experience’ and implement-
ing the following inclusion criteria: (a) all sources of
published literature, to gain a broad perspective of the use
of knowing, (b) papers written in English from various
countries, to gain a global perspective, (c) no time limit, to
gain a perspective of the evolution of the concept over time
and (d) a clear use of knowing as an essence of the subject
matter. Full doctoral dissertations were excluded as it was
necessary to read the sources in their entirety to develop a feel
for the manner in which the concept of knowing was used by
their authors. In addition, key citations, such as White’s
(1995) paper reviewing and critiquing patterns of knowing,
were obtained.
The search resulted in 134 papers, including 97 from
nursing, 17 from medicine, 11 from behavioural science and
nine from public health. The dates spanned 1978–2007 and
the papers originated from Australia, Belgium, Canada,
Germany, Ghana, Ireland, Italy, Japan, New Zealand,
Romania, Spain, Sweden, Switzerland, the United Kingdom
and the United States of America.
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S.A. Bonis
All reading, data collection and analysis were conducted by
the author. Each paper was read in its entirety to gain an
understanding of the manner in which the concept of knowing
was used, as well as the characteristics of the concept.
Tentative themes evolved to categorize the use of the concept
of knowing. The reference data and tentative themes were
organized in table format. Reading the papers, analysing the
use of the concept and categorizing the use of the concept into
the appropriate themes involved a repetitive iterative process.
Themes were refined throughout the process and papers were
read repeatedly to support the thematic decisions.
Findings
Analysis of the identified literature revealed that use of the
word ‘knowing’ covers several conceptual interpretations.
Three themes describing these interpretations were identified:
(1) knowing as a result of personal reflection, (2) technical
knowing and (3) knowing as a cognitive process (Table 1).
Medical researchers primarily use the concept to describe
technical knowing, such as the personal acquisition and
retention of specific knowledge contributing to a skill or
procedure. Behavioural scientists use knowing to describe
specific cognitive processing as well as to describe technical
knowing: knowing as a forced choice on questionnaires,
knowing of or about someone or procedural knowing.
Researchers in public health also use knowing to describe
technical types of knowing, including knowing someone or
something. Nurses use the concept of knowing in the context
of reflection on personal experience, including personal
knowing of a patient and knowing as personal reflection.
The concept of knowing as used in nursing involves
knowing in a context of awareness of experience in relation
to self or health for the individual as a whole. Personal
reflection is considered integral to the process of knowing.
Conceptual definition
The conceptual definition that resulted from this analysis is
that the concept of knowing in nursing involves a uniquely
personal type of knowledge, constructed of objective knowl-
edge interfaced with the individual’s awareness and sub-
jective perspective on personal experience; it is a dynamic
process and result of personal reflection and transformation.
Attributes of knowing
Attributes, antecedents and consequences are characteristics
that describe various aspects of the concept as it is used within a
discipline. Attributes are characteristics that provide a distin-
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guishable description of the concept (Rodgers & Knafl 2000).
Six attributes were identified; knowing: is a type of knowledge;
lies in personal experience; is personal knowledge; is shaped
through personal perspective; is a dynamic and changing
process; and evolves as a person lives and interacts in the world.
Knowing is a type of knowledge
Knowing is a type of knowledge that is formed through
personal experience. Although it can be argued that all
knowledge is personal (Wilkin 2002), knowledge is not
considered truly personal until it is applied (Leight 2002) and
reflected upon (Warelow 1997). Hattori et al. (2006) describe
empirically what is known of a good death so that nurses can
apply this knowledge to individual experiences of caring for
bereaved family members. Midwives shared knowledge with
women about childbirth so that they can apply that knowl-
edge to their own situation and make their own decisions
about childbirth (Fahy 2002).
Knowing lies in personal experience
Knowing is unique for each individual in that it lies within
personal experience. Knowing for each individual nurse is
unique. It is a result of knowledge gained through personal
and professional experience (Carper 1978, Warelow 1997,
Cody 2003) and is an interfacing of empirical, clinical and
personal knowledge (Antrobus 1997, Fenwick 1998, Fraser
et al. 2006, Gaydos 2004, Hattori et al. 2006, Little 2006).
As a nurse personally applies empirical knowledge in a clin-
ical experience and reflects on that experience (Cody 2003,
King 1995, Leight 2002, Seymour et al. 1997, Socorro et al.
2001, Wilkes et al. 2004), understanding (Hockenberry-
Eaton & Minick 1994, Owen-Mills 1998, Cody 2003) and
meaning arise (Holmes & Gregory 1998, Hattori et al. 2006),
resulting in personal and professional knowledge transfor-
mation (Wilkin 2002, Cody 2003). The knowledge that arises
through personal experience adds depth to the knowledge of
the discipline (Warelow 1997, Cody 2003).
One of the difficulties of accepting personal experience as a
form of knowledge and sharing the knowledge of that
experience is rooted in the difficulty that often arises from
attempting to express the meaning of the experience in words
(Gadow 1990). Personal and metaphorical narratives have
been used to reconstruct and find meaning in experience in
order to enhance further understanding of caring for patients
(Gaydos 2004, Merritt 2000).
Knowing is personal knowledge
Personal knowledge stems from reflection on personal expe-
rience; that is, reflection on the integration of scientific
JAN: THEORETICAL PAPER Concept analysis: knowing

Table 1 Use of knowing across health-related disciplines

Knowing as a Knowing as a
result of personal cognitive
Themes reflection Technical knowing process

Knowing
Personal Knowing as a forced Knowing of
knowing as personal choice on or about Procedural Cognitive
References Discipline of patient reflection questionnaire someone knowing processes

Ahorlu et al. (2006) Public health x

Arcury et al. (2001) Public health x
Iihara et al. (2004),. Public health x
Lutzen & Nordin (1993) Public health x
MacIntyre et al. (2001) Public health x
Maudsley et al. (2007) Public health x
NIH (2005) Public health x
Suzuki et al. (2006) Public health x
Yanowitz (2006) Public health x
Alcini et al. (1996) Medicine x
Camellini et al. (1987) Medicine x
Chen et al. (2001) Medicine x
Levi Setti et al. (2003) Medicine x
Magee & Edgerton (2003) Medicine x
Miller et al. (1994) Medicine x
Nadalin et al. (2007) Medicine x
Okazaki (1983) Medicine x
Overby & Kegeles (1994) Medicine x
Picard (2000a,b) Medicine x
Quadrani et al. (1980) Medicine x
Raposio et al. (2001) Medicine x
Rosas & Rosas (1987) Medicine x
Suteanu et al. (1987) Medicine x
Thornton et al. (2006) Medicine x
Weltermann et al. (2000) Medicine x
Younes (2005) Medicine x
Atkinson & Heath (1990) Behavioural Health x
Browne (1980) Behavioural Health x
Hirano et al. (2002) Behavioural Health x
Hofer (2000) Behavioural Health x
Krek-Konig (1982) Behavioural Health x
Martinez et al. (1995) Behavioural Health x
Piolino et al. (2007) Behavioural Health x
Rajaram (1993) Behavioural Health x
Terry et al. (2007) Behavioural Health x
Thomas & Clarke (1998) Behavioural Health x x
Wardle (1995) Behavioural Health x
Antrobus (1997) Nursing x
Artinian (1993) Nursing x
Cody (2003) Nursing
Fahy (2002) Nursing x
Fenwick (1998) Nursing x
Fraser et al. (2006) Nursing x
Gaydos (2004) Nursing x
Hattori et al. (2006) Nursing x
Hinck (2007) Nursing x

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S.A. Bonis

Table 1 (Continued)
Knowing as a Knowing as a
result of personal cognitive
Themes reflection Technical knowing process

Knowing
Personal Knowing as a forced Knowing of
knowing as personal choice on or about Procedural Cognitive
References Discipline of patient reflection questionnaire someone knowing processes

Hockenberry-Eaton & Minick (1994) Nursing x

Holmes & Gregory (1998) Nursing x
Howell & Pelton (2001) Nursing x
Jackson (2005) Nursing x
Johns (1999) Nursing x
Kavanaugh et al. (1997) Nursing x
King (1995) Nursing x
Leight (2002) Nursing x
Little (2006) Nursing x
Lutzen & Nordin (1993) Nursing x
Mentes et al. (2004) Nursing x
Nolan et al. (1992) Nursing x
O’Callaghan (2005) Nursing x
Owen-Mills (1998) Nursing x
Paley (2005) Nursing x
Pigg (1996) Nursing x
Seymour et al. (1997) Nursing x
Socorro et al. (2001) Nursing x
Thompson & Thompson (1990) Nursing x
Vance & Banford (1998) Nursing x
Vestal (1990) Nursing x
Volker (2001) Nursing x
Warelow (1997) Nursing x
Wilkes et al. (2004) Nursing x
Wilkin (2002) Nursing x
Williams & Inurita (2004) Nursing x

knowledge and the personal application of that knowledge
(Gadow 1990, Antrobus 1997). It is this personal type of
knowledge that is the most essential component of knowing
(Carper 1978). Only personal knowledge can answer ques-
tions of ‘What is it like?’ for an individual (Gadow 1990).
Moch (1990) describes personal knowledge through the
concept of personal knowing as an overlapping of experien-
tial knowing, interpersonal knowing and intuitive knowing.
The level of knowledge gained through personal experience
depends upon awareness of the experience, as well as on
reflection and synthesis of old knowledge with new (Carper
1978, Benner 1984, Moch 1990, King 1995).
Knowing is shaped through personal perspective
Knowing is a form of knowledge gained through experience
and shaped by the unique perspective of the individual
(Artinian 1993, Antrobus 1997, Williams & Inurita 2004),
thereby creating an individual reality (Barton 2004, Davidson
& Knafl 2006). Although another individual can be part of
the same experience, the perspective for each individual is
unique. Being aware of a patient’s unique perspective of the
health experience (Newman 1994, Parse 1997, Cody 2003,
Watson 2005) enables a nurse to understand the individual
reality for that patient (Radwin 1995, 1996) and develop a
specialized plan of care (Wilkin 2002, Jackson 2005, Watson
2005).
Knowing the patient involves understanding the perspec-
tives and patterns that are unique to the individual (Newman
1994, Radwin 1995, 1996, Parse 1997, 2001, Wilkin 2002,
Cody 2003, Jackson 2005, Watson 2005). A nurse who
understands the unique patterns of an individual patient is
able to recognize an alteration in those patterns that indicates

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that the patient is in pain (Seymour et al. 1997, Mentes et al.
2004). A nurse who is prepared to be open to cultural
perspectives on health is better able to provide culturally
sensitive care for particular cultural groups, such as the
Ojibwe people (Turton 1997), aboriginal people with diabe-
tes (Barton 2004) and African Americans who are obese
(Davidson & Knafl 2006).
Knowing is a dynamic and changing process
Knowing involves personal reflection on experience. Each
new experience is an opportunity for reflection and gaining
new knowledge. Awareness and reflection are iterative pro-
cesses that uncover the knowledge embedded in nursing
practice (Antrobus 1997; Howell & Pelton 2001), trans-
forming it into new knowledge to be cycled back into practice
(Jackson 2005). Members of the discipline must be willing to
continue this dynamic cyclical process and contribute to the
ongoing development of nursing knowledge (Cody 2003).
Knowing evolves as one lives and interacts in the world
Knowing is a type of knowledge that evolves as individuals live
and interact in the world (Rogers 1970, Cody & Mitchell
2002). Knowing is one of the keys to developing self-manage-
ment plans that lead to improved outcomes for people with
diabetes (Corbett & Cook 2004) and those with chronic
obstructive pulmonary disease (Fraser et al. 2006). It involves
putting together the pieces of health patterns and life experi-
ences in order to construct a plan that fits with the patient’s life.
Antecedents of knowing
Antecedents capture the characteristics that precede a con-
cept (Rodgers & Knafl 2000). The antecedents of knowing
are experience, awareness and reflection. Knowing occurs
through experience and is enhanced through awareness and
reflection.
Experience
Experience is used in the context of situations or activities in
which individuals interact with the environment (Benner
1984, Newman 1994, Johns & Freshwater 1998, Parse
2001). Experience in nursing refers to the experiences of
others, experiences in practice or experiences of patients.
Nurses share in the experiences of others through interaction
with them about the meaning of their experiences. In previ-
ous research, for example, children shared their experience of
cancer (Hockenberry-Eaton & Minick 1994), elders shared
their experiences of being oldest-old (Hinck 2007), and
family members shared their experiences of caring for a loved
one in home-based palliative care (Wilkes et al. 2004).
 2009 The Author. Journal compilation  2009 Blackwell Publishing Ltd
Concept analysis: knowing
Knowing in practice can involve the personal experiences
of clinical supervision (Antrobus 1997), interpersonal inter-
action with patients (Williams & Inurita 2004), mentoring
(Vance & Banford 1998), moral decision-making (Lutzen &
Nordin 1993), teaching patients (Little 2006), and caring for
mothers and infants (Thompson & Thompson 1990). Nurs-
ing experiences also evolve through the personal experiences
of caring for patients or family members (Seymour et al.
1997, Socorro et al. 2001, Mentes et al. 2004, Hattori et al.
2006).
Knowing evolves for patients through living a particular
health experience, such as stress (Nolan et al. 1992), the
premenstruum (King 1995), chronic obstructive pulmonary
disease (Fraser et al. 2006) or breastfeeding (Kavanaugh et al.
1997).
Awareness
Awareness refers to being open to an experience (Cowling
1993, Newman 1994, Parse 1997). A variety of activities
have been used to enhance awareness, such as writing poetry
(Holmes & Gregory 1998), stories (Fenwick 1998, Volker
2001, Leight 2002, Pardue 2004), personal narratives and
metaphor (Gaydos 2004), ethical mapping (Johns 1999),
videotaping (Little 2006), creative movement (Picard 2000)
and interactive reflection (Cowling 2000).
Reflection
Reflection involves looking both inward and outward at
experience to develop an understanding and create meaning
(Newman et al. 1991, Johns & Freshwater 1998). Knowing
in nursing is developed through ongoing reflection on
practice experiences (Antrobus 1997, Holmes & Gregory
1998, Jackson 2005, Johns 1999, Lutzen & Nordin 1993,
O’Callaghan 2005, Owen-Mills 1998, Warelow 1997,
Wilkes et al. 2004, Williams & Inurita 2004), such as
decision-making (Thompson & Thompson 1990), conflict
(Vance & Banford 1998) and ethics (Johns 1999, Volker
2001). Nurses also reflect on their specific involvement
with patient care, such as caring for patients with cancer
(Howell & Pelton 2001), patients who are cognitively im-
paired (Mentes et al. 2004) and women (Leight 2002).
Others reflect on experiences in specific situations, such as
with students (Diekelmann & Mendias 2005, Little 2006),
research (King 1995, Pigg 1996, Jones 2003), families
(Nolan et al. 1992, Socorro et al. 2001) and midwifery
(Fenwick 1998, Shallow 2001, Fahy 2002). Reflection on
the experience of nurse–patient relationships leads to a
deeper understanding of the needs of patients and devel-
opment of new nursing knowledge (Cumbie 2001, Wilkin
2002).
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S.A. Bonis
Knowing for patients is enhanced through reflection on
their health experiences as they interface with their lives, such
as children (Hockenberry-Eaton & Minick 1994) and adults
(Lane 2005) reflecting on their experiences with cancer and
women reflecting on healthcare decision-making (King 1995,
Fahy 2002).
Consequences of knowing
Consequences describe the situation that follows the occur-
rence of the concept (Rodgers & Knafl 2000). The conse-
quences of knowing include understanding, finding meaning
and transformation.
Understanding
Through awareness and reflection on experience, nurses are
better able to understand the uniqueness of individual
patients and plan therapeutic interventions accordingly
(Antrobus 1997, Cody 2003, Hinck 2007, Holmes &
Gregory 1998, Jackson 2005, Newman 1994, O’Callaghan
2005, Owen-Mills 1998, Parse 1997, Radwin 1996, Williams
& Inurita 2004). Nurses working with older people have
used reflection to understand their personal values and
attitudes towards these clients better in order to enhance
knowing what action to take when confronted with abuse
(Kingsley 2002). Understanding individual attitudes toward
death enables nurses to implement culturally sensitive inter-
ventions for patients and families at the end of life (Hattori
et al. 2006, Rittman et al. 1997, Socorro et al. 2001, Stiles
1994). Nurses who develop a broader understanding of
suffering also develop a more global approach in thinking
about suffering (Georges 2004).
Finding meaning
Meaning is the essence of experience (Swanson 1991), and
is uncovered as one reflects on experience and understands
how the experience interfaces with life. However, it is
often difficult to uncover and describe the meaning within
experience (Gadow 1990). Writing poetry is one way for
nurses to connect with the meaning that is hidden within
their practice experiences (Holmes & Gregory 1998).
Nurses who have found meaning in their own personal and
professional experiences can relate that meaning to their
professional practice (Antrobus 1997, Cody 2003, Hinck
2007, Holmes & Gregory 1998, Jackson 2005,
Leight 2002, O’Callaghan 2005, Owen-Mills 1998,
Williams & Inurita 2004, Yorks & Sharoff 2001) and
use it in the professional relationships that they develop
with patients (Cowling 2005, Leight 2002, Rogers 1970,
Swanson 1991).
1334  2009 The Author. Journal compilation  2009 Blackwell Publishing Ltd
Stories are one way for patients to find meaning in their
health-illness experiences (Swanson 1991). Patients who
reflect on their own health experiences understand those
experiences in new ways (Gaydos 2004) and are able to
generate new knowledge by ‘constructing and reconstructing’
the meaning of their experiences (Yorks & Sharoff 2001, p.
27). Understanding their experiences with cancer has helped
children find meaning in their new way of life (Hockenberry-
Eaton & Minick 1994), and older people who reflected on
their past experiences have found meaning in their future
lives (Hinck 2007). Women with breast cancer were able to
discover what was most meaningful in their life (Moch 1990)
and mothers who reflected on their breast feeding experience
were able to find meaning that helped them to see the
advantages of overcoming inconvenience for the benefit of
their infants (Kavanaugh et al. 1997).
Transformation
Transformation is an ongoing process of change involving
knowing, understanding and finding meaning in experience.
Knowing the meaning of their experiences and the experi-
ences of their patients helps nurses add depth to their
knowledge, improve their practice and contribute to the
development of the discipline (Antrobus 1997, Warelow
1997, Holmes & Gregory 1998, Owen-Mills 1998, Wade
1998, Howell & Pelton 2001, Wilkin 2002, Cody 2003,
Chinn & Kramer 2004, Williams & Inurita 2004,
O’Callaghan 2005, Hinck 2007). Knowing what contributes
to a good day in nursing leads to improved job satisfaction
for new nurses (Jackson 2004). Students who reflect on their
clinical experiences transform objective technical knowledge
into meaningful insights for their own practice (Hallett 1997,
Kidd & Tusaie 2004, Harris 2005).
Knowing the meaning of their own health experiences
helps patients understand the experiences in new ways,
thereby promoting healing (Gaydos 2004), empowerment
(Fahy 2002), strength (Hockenberry-Eaton & Minick
1994), self-care management (Fraser et al. 2006) and new
perspectives on life (Danforth & Glass 2001). Older people
who find meaning in their past experiences realize that they
define themselves through their experiences, and that
knowing the past is not only critical to understanding the
present, but also offers new insights and possibilities for
the future (Hinck 2007).
Knowing that some struggles are beyond resolution in the
immediate setting (Vance & Banford 1998) is inevitable;
however, what has helped families cope while waiting for a
heart transplant was knowing that the family had the
strength to deal with problems as they arose (Nolan et al.
1992).
JAN: THEORETICAL PAPER
Exemplar
The following exemplar was drawn from the literature for the
purpose of demonstrating the concept in action (Rodgers &
Knafl 2000). In a study by Kidd and Tusaie (2004), students
were asked to submit weekly journals reflecting on their
experiences in a mental health setting. The assignment was
designed to emphasize a therapeutic use of self. Instead, the
students focused on the objective aspects of assessment and
evaluation, which interfered with the development of an
empathic and therapeutic self.
To redirect the project in the intended direction, educators
asked specific questions about the clinical experience and
asked for personal goals. The students persisted in submitting
objective assessment data. The educators finally amended the
assignment and incorporated an aesthetic approach. They
asked the students to write a poem about either their clinical
experience or a specific experience from the perspective of a
client (Kidd & Tusaie 2004).
The poetry provided a vehicle for the students to become
aware of the self, as well as the experience of working with
people with mental health problems. The students were able
to recognize their fears and how their personal experiences
with mental health affected their present situation. Through
writing poetry, they were able to reflect on the experience,
develop an understanding of mental health experiences for
self and clients, and understand the experience from a
different perspective. Reflecting on the experience and
writing the poetry successfully moved students’ knowledge
beyond objective classifications to knowing the patient as a
whole. They realized that they had had preconceived ideas of
caring for an individual with mental illness. Their knowledge
of self and others was transformed through aesthetic explo-
ration of patients living the experience (Kidd & Tusaie 2004).
Discussion
The aim of this analysis was to describe the evolution of the
concept of knowing in nursing since Carper’s introduction of
empirical, aesthetic, ethical and personal patterns of knowing
as a foundation of nursing knowledge in 1978. Use of the
term ‘knowing’, as well as other descriptive terms that fit the
same conceptual thought (Table 2), was found with increas-
ing frequency, and has evolved from discussions of patterns
and ways of knowing in nursing to application of knowing as
a concept in research and practice development. In addition,
discussions involving the concept of knowing have evolved in
four areas, namely patterns and ways of knowing, theory and
knowledge development, practice development and research
application.
 2009 The Author. Journal compilation  2009 Blackwell Publishing Ltd
Concept analysis: knowing
Analysis of the concept of knowing in nursing was
complicated due to the complex environment in which nurses
live and work. Nursing research and practice occur in an
interdisciplinary environment in which nurses are called upon
to interweave empirical knowledge with personal experiences
of applying that knowledge (Antrobus 1997, Fraser et al.
2006, Leight 2002, Rycroft-Malone et al. 2004). Empirically
derived knowledge, which contributes to the research, plan-
ning and management of patient care, is comprised of
knowledge from multiple disciplines and contributes to a
common foundation of health and illness (Sullivan-Marx
2006, Barnsteiner et al. 2007, Lamb 2007, Munhall 2007).
Understanding the concept of knowing requires understand-
ing the distinction between the empirical facet and the
personal experience of interacting with the empirical facet or,
in other words, the distinction between the scientific facts
about a disease process and the personal experience of living
with that disease process.
Nurse researchers incorporate specific methodologies that
promote description, understanding and interpretation of
personal experience. Through awareness and reflection, the
meaning of personal experiences of health and illness are
illuminated. Through understanding the meaning of health
and illness, individuals are able to transform previous
knowledge into a new kind of knowledge that interfaces
objective empirical knowledge with the subjective reality that
is uniquely theirs as they live and interact with the world
(Warelow 1997, Howell & Pelton 2001).
Personal experience in nursing is further complicated by
the individual but overlapping personal realities and experi-
ences of patients and nurses. Nurses interweave empirically
derived knowledge with their own personal experiences of
applying that knowledge. This personal experience is then
interwoven with the personal experiences of each patient.
This requires multiple levels of awareness and reflection on
experience to result in nurses’ and the patients’ personal
understanding and meaning. Both nurses and patients are
transformed through the same process, but the transforma-
tion for each is unique to the individual.
These complexities require nurses to enter into patient care
planning with clear understanding of the type of knowledge
that is specific to nursing, particularly during interdisciplinary
collaboration. Nurses must clearly communicate the unique
perspective that nursing brings to the effort (Leight 2002,
Moore 1990, Munhall 2007). Although different disciplines
are founded on different foundations and are concerned with
different perspectives of knowledge (LeCompte 1990), sim-
ilar terms are used that imply different conceptual interpre-
tations. These differing uses of similar terms emphasize the
need to be clear in the manner in which concepts are used in
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S.A. Bonis

Table 2 Surrogate terms for knowing

Words or phrases that were Concepts related to the subjective
used in place of knowing aspect of knowing

Anecdotal experience (NIH 2005) Clearly, consciously remembered (Terry et al. 2007)
Personal knowledge (Hofer 2000, NIH 2005, O’Callaghan 2005) Judged as known (simply known) (Terry et al. 2007)
Applied knowing (Alcini et al. 1996) Judged as remembered (Terry et al. 2007)
Ways of knowing (Antrobus 1997, Holmes & Gregory 1998, Knowledge about one’s personal past (Terry et al. 2007)
Howell & Pelton 2001, Leight 2002, O’Callaghan 2005, Prerecalled (Terry et al. 2007)
Little 2006, Lordly 2007) Reflective self-awareness (Browne 1980)
Patterns of knowing (Holmes & Gregory 1998, Woodman et al. Remember/know and sense of
2002) just knowing (Piolino et al. 2007, Rajaram 1993)
Knowing in nursing (Owen-Mills 1998) Nurse as knower (Antrobus 1997)
Knowing how (Rosas & Rosas 1987, Martinez et al. 1995, Familiar with (Fraser et al. 2006)
Arcury et al. 2001, Fahy 2002, Maudsley et al. 2007) Awareness of the sensibilities (Holmes & Gregory 1998)
Knowing what (Quadrani et al. 1980, Artinian 1993, Hock From the perspective of Iihara et al. (2004)
enberry-Eaton & Minick 1994, Younes 2005, Fraser et al. 2006) Levels of knowledge (Jackson 2005)
Knowing that (Browne 1980, Picard 2000; Vance & Banford Inner truth (Krek-Konig 1982)
1998, Warelow 1997, Weltermann et al. 2000) To know (Okazaki 1983)
Knowing which (Camellini et al. 1987) Not knowing how (Martinez et al. 1995)
Knowing when (Magee & Edgerton 2003, Maudsley et al. 2007) Not knowing where (Suzuki et al. 2006)
Knowing about (Jackson 2005) Without knowing (Raposio et al. 2001)
Knowing more (Wardle 1995, Pigg 1996) Knew (Martinez et al. 1995)
Knowing someone (Overby & Kegeles 1994, Thomas & Clarke Information (Mentes et al. 2004)
1998, Thornton et al. 2006, Yanowitz 2006) Related uncertainty (Maudsley et al. 2007)
Habits of knowing (Atkinson & Heath 1990)
Believing (Chen et al. 2001)
Perceptions of (Artinian 1993)
Perceptive experiences (Holmes & Gregory 1998)
Knowledge gained through the process of writing (Holmes &
Gregory 1998)
Knowledge and personal experience (Thompson & Thompson
1990)
Kinds of knowing (Leight 2002)
Aesthetic knowing (Gaydos 2004; Leight 2002)
Ethical knowing (Cody 2003)
Personal knowing (Fraser et al. 2006, Howell & Pelton 2001,
Little 2006)
Professional knowing (Fraser et al. 2006)
Scientific knowing (Cody 2003)
Gaining an understanding of (Fraser et al. 2006)
Understood (Gaydos 2004)
Understanding (Hockenberry-Eaton & Minick 1994)
Personal understanding (Miller et al. 1994, Owen-Mills 1998)
Experience with reflection (Howell & Pelton 2001)
Reflective experience of (Vance & Banford 1998)
Expressive, creative, intuitive application of knowledge
(Leight 2002)
Contextual, phenomena-centered knowledge (Leight 2002)
What it means to (Lordly 2007)
Silent knowing (Volker 2001)
Internal and external constructions (Warelow 1997)
Personal knowledge (Wilkin 2002)
Insight into and understanding of (Williams & Inurita 2004)

NIH, National Institutes of Health.

1336  2009 The Author. Journal compilation  2009 Blackwell Publishing Ltd
JAN: THEORETICAL PAPER
What is already known about this topic
• Knowing is used in the context of knowledge, but its
meaning in nursing is not clear.
• Various ways of knowing have been identified in the
nursing literature.
• The attributes, antecedents and consequences of
knowing have not been identified through concept
analysis.
What this paper adds
• Knowing is a dynamic process of knowledge develop-
ment enhanced through awareness and personal reflec-
tion on experience.
• The conceptual use of knowing as personal reflection on
experience is unique to nursing.
• The dynamic process of knowing enhances theory,
research, practice and education.
Implications for practice and/or policy
• Research involving the personal experience of health
and illness generates knowledge that contributes to the
foundation of nursing knowledge.
• Further examination of interdisciplinary uses of the
concept of knowing would add clarity to the type of
knowledge sought in research and the role that each
contributes to multidisciplinary collaboration.
• Further analysis is needed to identify various app-
roaches that embrace the concept of knowing.
order to clarify interdisciplinary information exchange and
prevent confusion and conflict.
An interesting example of the differing uses of the concept
of knowing involves three separate studies included in the
sample of papers, one from medicine and two from nursing.
Each involved knowing patients’ experiences with pain. The
study from medicine concerned knowing the biomedical
aspects of pain for a particular patient in terms of the
appropriate pharmaceutical intervention (Miller et al. 1994).
The studies from nursing involved knowing the personal
patterns of infants (Seymour et al. 1997) and cognitively
impaired adults (Mentes et al. 2004). The nurses were able to
recognize a change in pattern that indicated pain and the need
for intervention. The researchers from medicine and nursing
all addressed knowing patients’ experiences with pain;
however, knowing in medicine was from a technical perspec-
tive, but in nursing it was a result of reflection on personal
experience with the patient.
 2009 The Author. Journal compilation  2009 Blackwell Publishing Ltd
Concept analysis: knowing
Carper (1993) encouraged others to broaden the quest for
nursing knowledge in a manner that neither accepts nor
rejects knowledge. Scholars and researchers have embraced
the challenge to broaden the organization of nursing knowl-
edge (Jacobs-Kramer & Chinn 1988, Tanner et al. 1993) and
to answer epistemological and ontological questions (Silva
et al. 1995). Nursing knowledge has evolved in accordance
with Carper’s original intent, which was to further nursing
knowledge by interweaving multiple patterns of knowing
(Silva et al. 1995, Schmidt et al. 2003) to form a whole of
knowing (Smith 2000). Nursing has come to value the
wholeness of knowing as a dynamic interweaving of various
patterns of knowing that evolves as individuals live and
interact with the world. As nursing has come to use the
concept of knowing in this unique manner, Carper’s discrete
epistemological threads of knowing have been interwoven
with the ontological threads of meaning and being into a
single tapestry. Through the incorporation of experience,
awareness and reflection, this tapestry of knowing in nursing
is a foundation of knowledge that has made a unique
contribution to the knowledge-base of nursing and interdis-
ciplinary collaborative efforts.
Study limitations
A limitation of this analysis is that the data collection and
analysis were completed by one individual and therefore
constitute only one perspective. However, this single per-
spective can serve as a launching point for others to expand
on and to incorporate descriptions of the concept of knowing
into their research and discussions.
Conclusion
Knowing is a type of knowledge that is constructed through
experience, shaped by reflection and manifested by meaning.
Knowing is unique to each individual, is subjective in nature
and answers different questions from empirically driven
methods. ‘Knowing’ questions are those that search for
meaning and can only be revealed from the perspective of the
human living with the world.
It is through its focus on the person living and interacting
with the environment that nursing has carved out its own niche
in healthcare research. It is not merely through use of the word,
but through living the experience of knowing, that the
foundation of nursing has developed the strength to support
knowledge constructed through reflection and meaning.
This clarification of the concept knowing is not conclusive;
rather, it is a starting point from which to move forward in
the evolution of nursing knowledge. It offers a perspective on
1337
S.A. Bonis
knowing that is unique for nursing and in the arena of health
care. Further examination of the interdisciplinary uses of the
concept of knowing would add clarification to the types of
questions asked in the various healthcare disciplines, the type
of knowledge that is sought in research and the role that
each contributes to interdisciplinary collaboration. A more
in-depth study of the use of the concept of knowing within
the discipline of nursing could illuminate nursing theories
that embrace the concept. This would lend support to the
findings of this study and contribute toward strengthening a
unified foundation of nursing knowledge.
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Conflict of interest
No conflict of interest has been declared by the author.
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The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the
advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and
scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management
or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers.

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