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Spiritual Knowing

Another Pattern of Knowing in the Discipline

Willis, Danny G., DNS, RN, PMHCNS-BC, FAAN; Leone-Sheehan, Danielle M., MS, RN

doi: 10.1097/ANS.0000000000000236
The Focus of the Discipline
Free

Fundamental patterns of knowing in nursing have historically served to clarify the substance and structure of the discipline, significantly contributing to nursing's body of knowledge. In this article, we continue the scholarly conversation on patterns of knowing in nursing by advancing spiritual knowing as a pattern of knowing that helps advance nursing's agenda toward universal well-being and critical during this time toward interdisciplinarity. Implications for nursing are explored in relation to enduring and new questions that require our attention related to human beings, their environments, and healing.

University of Wisconsin-Madison School of Nursing (Dr Willis); and William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Ms Leone-Sheehan).

Correspondence: Danny G. Willis, DNS, RN, PMHCNS-BC, FAAN, University of Wisconsin-Madison School of Nursing, 1157 Signe Skott Cooper Hall, 701 Highland Ave, Madison, WI 53705 (dgwillis@wisc.edu).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

THIS is an interesting time in our history as a discipline. Questions and tensions are being raised about the future of our discipline. One of the key questions revolves around whether we will pay our allegiance toward an emphasis on interdisciplinarity over developing our own disciplinary focus and its ongoing evolution. There is reason to believe that these tensions prompted this special edition of Advances in Nursing Science dedicated to the focus of the discipline (evidenced in the call for articles). In relation to this current tension, it is imperative that we be astute in our own discipline and in interdisciplinary contexts going forward. Members of the discipline need to have stunning clarity about the foci and patterns of knowing that best serve our goals as the discipline of nursing in fostering human health, humanistic nursing care, and societal well-being. A close reading of nursing's history exemplifies the transformative power of identifying nursing's phenomena of concern in relation to human health and environment and fulfillment of nursing's mission, including, but not limited to, the identification and formalization of nursing's extant meta-paradigm—human being/person, environment, health, and nursing1 to guide our discipline and profession.

A clear understanding of the key dimensions that define us as a discipline (ie, nursing's perspectives, definitions of nursing, domains, and patterns of knowing)2 is requisite to appropriately situate us as members within our own discipline and within interdisciplinary contexts of education, practice, research, administration, and policy. This clarity of focus is necessary in order that our professional goals on behalf of individual and societal well-being are not marginalized within interdisciplinary fora. If nurses uncritically move toward more interdisciplinary frameworks, without deep investment in the ongoing development of the substance and syntax of the discipline, we are at risk.3 At this time in our history, are we situated at the cusp of devolving into an amalgamation or blurring with other disciplines or at the cusp of standing tall and bold within our own discipline as we ever evolve with the changes in society, nursing, health care, and within interdisciplinary contexts? The outcome depends on our choices of allegiance and how and where we focus our scholarship and practice energies.

As noted previously, one of the key dimensions defining our discipline is the identified patterns of knowing in nursing. Nurses' multiple patterns of knowing shape the realm of nursing's possibilities and what nurses value and attend to. In this article, we advance the discussion on patterns of knowing in the discipline by describing and explicitly formalizing spiritual knowing as a pattern of knowing in nursing. Without the ability to name, give clear language to, and explicate the phenomena of concern to the discipline, nurses' knowing about nursing (qua nursing) is at risk of subjugation to other disciplines and professions.

Spiritual knowing as a pattern of knowing in nursing is related to the extant meta-paradigm but distinct from the meta-paradigm. That is, whole human beings (whose nature includes a spiritual aspect) exist within their environments. Human beings' health is an emergent of human environment throughout the life process. Human beings' health is integral with one's human spiritual nature. Nursing focuses on knowledge and actions that benefit the health of whole human beings. Human beings have the capacity to engage in spiritual knowing. Spiritual knowing as a pattern of knowing in nursing, at face value and as we explicate it in this article, is related to nursing's meta-paradigm.

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Statements of Significance

What is known or assumed to be true about this topic:

We understand nursing's patterns of knowing as central to defining the discipline. As authors of this article, we have studied empirical, esthetic, personal, ethical, sociopolitical, and emancipatory ways of knowing as students and disciplinary scholars. The patterns of knowing structure the way we practice as nurses and the way we work with students and professionals from other disciplines, translating a unique perspective that is nursing.

What this article adds:

We constructed this article to advance spiritual knowing as a pattern of knowing in nursing. This article enriches the ongoing conversation in nursing about ways of knowing that reflect our past, present, and unfolding future. We situate spiritual knowing within the larger context of the evolving discipline, entertaining enduring and new questions pertinent to our disciplinary mission and goals to support human health and well-being.

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FOCUS OF THE DISCIPLINE

Spiritual knowing is advanced as a distinctive pattern of knowing in nursing, and thereby a focus of the discipline. A discipline is demarcated by its purposes, structure, substantive focus, reasoning, and thought patterns.2 The nursing discipline is identified by a central unifying focus and orientation.4 , 5 Multiple ways of knowing in the discipline in concert with the substantive foci of the discipline, nursing discipline–specific theories, borrowed theories clearly reformulated with nursing's perspectives for nursing's purposes, and nursing theory–guided practice constitute our essence. Thus, ongoing identification and explication/theorizing of phenomena of concern to nursing, epistemological diversity, and multiple patterns of knowing are necessary for the discipline. Multiple ways of knowing help nurses in collaboration with other professionals when addressing human health issues within the multidimensional contexts of complex human beings and their environments in health and illness situations.

Forty years ago, Donaldson and Crowley's proposal that “nursing studies the wholeness or health of humans, recognizing that humans are in continuous interactions with their environments”6 (p119) brought clarity to the discipline. In an ongoing fashion, other proposals were advanced that brought clarity to the discipline including Pender's7 notion of human health as a life cycle process, the proposition by Newman et al8 that nursing focuses on caring in the health experience, Meleis and Trangenstein's9 transitions processes in promoting human well-being, and Reed's10 view of nursing as human beings' processes of well-being. In a special 2008 edition of Advances in Nursing Science devoted to the focus of the discipline, various authors proposed that the discipline includes a clear focus. These foci were on the nurse-patient relationship viewed through the concepts of health, caring, consciousness, mutual process, patterning, presence, and meaning11; wholeness, consciousness, caring, pattern, transcendence, transformation, relationship, and meaning12; “humanness in the health circumstance”13; and facilitating humanization, meaning, choice, quality of life, and healing in living and dying.4 These illuminations helped us remember and become reacquainted with the rich central meanings of our disciplinary focus and the need for empirical and philosophical inquiry.14

At this time in our history, from our perspective as nurses grounded in the unitary-transformative paradigm of nursing,8 it seems wise, and timely, to hereby explicate spiritual knowing as a pattern of knowing in nursing. We believe that spiritual knowing, in concert with other explicated patterns, can help us (as nurses) have a clear conception of spiritual knowing that is distinct from other patterns and the language needed to work collaboratively with other concerned disciplines to craft wise solutions and meaningful caring-healing practices for promoting universal well-being. The spiritual nature of whole human beings calls for nurses to engage in spiritual knowing.

With the tensions existing toward a move to interdisciplinarity, our disciplinary foci should be amplified. This amplification is called for within our education, research, theory, practice, and philosophical inquiries while providing room for new nursing-centric developments in the discipline. This is important lest we become mesmerized by other bodies of knowledge and extra-disciplinary concepts devoid of a nursing focus and be led astray from the very core of our being as a discipline. This does not mean that we as disciplinary members are closed off to new emergent ways of knowing in concert with other disciplines and professions whom we collaborate with. New and expanded nursing praxis methodologies may emerge over time that have yet to be explicated from a nursing perspective. One of the patterns of knowing particularly important to explicate at this time in our history is spiritual knowing.

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SOCIAL TIMES THAT CALL FOR AN EXPLICATION OF SPIRITUAL KNOWING

The advancement of spiritual knowing as a pattern of knowing in nursing is particularly important, given the contemporary focus on interdisciplinarity. As noted previously, an uncritical move to interdisciplinarity may result in the blurring of our discipline if we are not attentive to our own goals and foci. Furthermore, in concert with socially unjust states of affairs among human beings the world over, we believe that spiritual knowing in nursing is important to be explicated. We live within a complicated social, historical, and political time throughout the universe, existing in a world marked by myriad threats to well-being: violence, environmental hazards, climate change, health inequities, drug crises, toxic stress, ruthless killings, suicide, technology/information explosion, and other humanitarian crises. These are conditions that can be seen as mirroring ways of knowing antithetical to spiritual qualities. Such widespread problems that affect the well-being of the universe require spiritual consciousness and interconnected ways of knowing in our search for wise solutions. If even one of us is vulnerable to health inequities, dehumanization, and social political atrocities undergirded by antithetical spiritual qualities such as indifference, objectification, hatred, killing, dehumanization, exploitation, and so on, are we not all vulnerable? One is left pondering about our discipline and the well-being of humankind at large: Where have we been—our past, Who are we—current, and Where are we headed—future? Have we reached a tipping point?

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PATTERNS OF KNOWING IN NURSING

Carper's15 philosophical essay describing 4 fundamental patterns of knowing in nursing conditioned the way nurses conceptualize the discipline's substantive knowledge and the organization of professional nursing knowledge for practice. Multiple ways of knowing are needed in nursing with its focus on the health of holistic human beings and their environments. Thus, Carper's identified patterns of knowing continue to influence nursing education, practice, and research, as have other patterns of knowing. Her analysis of empirical, esthetic, personal, and ethical patterns of knowing as fundamental to the discipline provided clarity about nurses' ways of knowing with implications for nurses' being and doing. Our interpretation of Carper's descriptions reflects the interdependence of these ways of knowing. The ways of knowing are related to the extant meta-paradigm. That is, each pattern described in this article enhances knowing the human being and environment for nursing's focus on human health and well-being. Empirics is the pattern perhaps most familiar to nurses. Carper's view of empirics reflects the formal development of nursing's theoretical descriptions, the “facts” and the more traditional view of the “science” of nursing. Esthetics, on the contrary, reflects the nurse's felt experience and perception of immediate human need in particular nursing situations and appropriate nursing responses/actions (Carper's use of the example of empathy). Personal knowing stems from the interpersonal nature of nursing. It reflects nurses' knowing self, coming to actualize one's self/identity, and knowing self-in-relation, including therapeutic interpersonal engagement. Ethical knowing reflects nursing values of service to humankind and respect for human dignity, complexity in choice/decision making, and moral actions.

Scholars who expanded on prior work and introduced new conceptions of patterns of knowing into the nursing literature advanced our disciplinary focus. White's16 sociopolitical knowing provided a view into the contextually focused awareness needed by nurses in relation to the social and political contexts surrounding nurses and the humans they care for and the sociopolitical climate in which nursing as a profession exists. Chinn and Kramer's17 explication of emancipatory knowing evolved the focus of the discipline in relation to the pattern of the whole. They describe the critical work nurses engage in toward aims centered on emancipation/freedom. This emancipatory work they describe necessitates dismantling blockages to freedom such as dogma, oppressive structures, and limited thought models, especially in relation to health and social injustices (and within the discipline). Thereby, they explicate patterns of knowing that are reflective of the meta-paradigm concepts of human being, environment, health, and nursing for promoting and actualizing social justice for nursing's purposes.

Mirroring emancipatory aims in nursing, other recent scholarship by many nursing scholars have been collected in a compendium of emancipatory philosophies and practices,18 documenting a variety of powerful efforts and strategies that work at the level of freedom and transformation of society. As one example, authors within the compendium speak of nursing's liberation from institutional confinement to facilitate humanization in its fullest sense:

Liberation of the profession from institutional confinement begins with the critically reflective and creative “essential freedom” of nursing consciousness that will devise the necessary changes to expand the range of “nursing effective freedom” for social justice action. Only then will we be able to become full actors in the efforts to transform society and facilitate humanization in the fullest sense.19 (p263)

We submit that the multiple patterns of knowing clarified by nursing's scholars have elucidated an evolving pattern of the whole that is continually changing as we ever evolve as a discipline. Each pattern of knowing, working in concert, ultimately underpins nurses' comprehensive understanding of holistic human beings and their health within the context of their environments, thereby being inextricably linked with the meta-paradigm concepts. The patterns are valuable as they reflect nursing's epistemological and ontological perspectives and are useful for guiding knowledgeable nursing actions. The patterns help define who we are and what we stand for, our science, exquisite caring, therapeutic use of self, ethical knowing and actions, sociopolitical consciousness and strategies, and emancipatory aims. And at times, we may even need to step back from what we know, deliberately taking a stance of unknowing in order to see more clearly.20 Multiple patterns of knowing in nursing have undergirded our discipline and are needed for our valued purpose and service to humankind.

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SPIRITUALITY AND SPIRITUAL

Describing spiritual knowing for the discipline is not possible without first delving into what is known about the concept “spirituality” in relation to nursing's purposes. The explicit focus on spirituality in nursing has a long history, including the spiritual emphasis in nursing reflected by Florence Nightingale as a key figurehead of modern nursing.21 A comprehensive review of the “spirituality” concept is beyond the aim and scope of this article. Therefore, we summarize and highlight selected literature and research studies in the nursing and related science that conceptualize and describe spirituality in relation to health. We draw important distinctions between spirituality and religion.22–26 Definitions of spirituality put forth in the nursing literature share commonalties. These commonalities are individually defined,22 , 24 , 27 , 28 process/journey orientation/quest seeking/unfolding,23–25 , 28 , 29 mea-ning and purpose in life,22–25 , 28–31 transcendent perspective,25 , 26 , 30 , 31 and experienced in relationship with self/others/higher power,22–25 , 27 , 29–31 or Source.32 Furthermore, according to dictionary meanings, “spiritual,” in its adjective form, is defined as “relating to or affecting the human spirit or soul as opposed to material or physical things.”33

Based on the literature, nursing's central disciplinary foci, and our interpretive work together, we constructed a definition of spirituality for the purposes of nursing. We define spirituality as an innate feature of being human reflected in the human spirit, whereby human beings experience meaning and purpose, awareness of a greater reality, and connection with others, nature, and/or to the infinite/sacred/divine, Source, or a Supreme Being, which may or may not involve religion. Defining spirituality for nursing is essential as nurses in several studies cite a lack of definitional clarity as a barrier to the participating in spiritual nursing care.34–38 A clear, open, and flexible definition of spirituality, such as the one we have provided previously, is needed to guide spiritual knowledge and practice in nursing.

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SPIRITUAL KNOWING

We define spiritual knowing as human beings' perceiving and appreciating of nonmaterial spiritual qualities and experiences that provide meaning and purpose, awareness of a greater reality, and uplifting of the human spirit. Nonmaterial spiritual qualities and experiences foster a sense of well-being and include, but are not limited to, patience, gentleness, compassion, hope, forgiveness, humility, gratitude, unity, and love, as well as connection to the sacred/divine as individually defined. These nonmaterial qualities and experiences uplift the spiritual consciousness of humankind. Thus, spiritual knowing is distinguishable from the other explicated patterns of knowing described earlier.

Our definition of spiritual knowing, similar to our definition of spirituality, offers a broad and inclusive perspective for nursing. Through the thought pattern of spiritual knowing, nurses are tuned into spiritual qualities that aid in facilitating wholeness, humanization, meaning, healing, choice, and processes of well-being worldwide. Caring, humanization, meaning, and healing of self-other-universe occur when we as nurses (and humanity) embody and live out spiritual qualities and experiences that uplift the human spirit and the spiritual consciousness of humanity.

In relation to spiritual knowing, spiritual knowledge is that which is known, experienced, named, and given voice to in relation to spiritual knowing. According to the Merriam-Webster online dictionary, knowledge is

the fact or condition of knowing something with familiarity gained through experience or association; acquaintance with or understanding of a science, art, or technique; ... the sum of what is known: the body of truth, information, and principles acquired by humankind.39

Thus, spiritual knowledge falls within the broad range of fact or condition of knowing something with familiarity gained through experience or association. Spiritual knowledge is inclusive of, though not limited to, religious beliefs and practices. Human beings may experience, express, and expand their spiritual knowing through participation in nonreligious practices and through organized religion. While the nursing literature is careful to separate religion from definitions of spirituality that do not include religion, neither conception can be outright excluded from spiritual knowledge, given the diverse manifestations of spiritual experiences.

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THEORETICAL BASIS FOR SPIRITUAL KNOWING

We are not alone in perceiving spiritual knowing as a pattern of knowing. In this article, we have chosen to illuminate spiritual knowing from its implicit status within the discipline by formally naming and explicating it as a pattern of knowing in nursing. This explication is different from, but supported by, the explicit naming of spirituality within several nursing conceptual models and theories. Explicating spiritual knowing as a pattern of knowing in nursing is an important contribution, given that nursing has been grounded in a wholistic view of the human being, accounting for the spiritual nature of human beings from a Christian call to service. This grounding dates before the Nightingale era, but more scholastically since the time of Florence Nightingale's healing ministrations and documentation of notes on nursing.40 Nightingale was oriented toward spiritual knowing in her accounts of being called (by God) into the service of bettering humanity through her ministrations to the sick, poor, imprisoned, and on behalf of societal health and well-being.41 Spiritual qualities of joy, peace, love, and compassion throughout time have been known to elevate the human spirit and spiritual consciousness beyond one's tendency to focus merely on the body physical or a material sense of life. Thus, perceiving and appreciating spiritual qualities and experiences are consistent with notions of fostering well-being in the nursing literature. Indeed, nurses are in a prime position to cultivate well-being and spiritual evolution of self beyond ego.42

A comprehensive historical accounting of what we interpret as spiritual knowing in the discipline is beyond the scope of this article, although no doubt a worthy endeavor to be pursued. The basis for spirituality in nursing practice is supported in the writings from numerous nurse theorists. Many nursing conceptual models and theories have addressed the spiritual nature of human being and spiritual qualities. A sampling of nursing theoretical perspectives on spirituality will follow.

Neuman43 in the Neuman's Systems Model identifies spirituality as one of the essential variables in the client system. The variables, which also include physiological, psychological, developmental, and sociocultural, are in constant interaction and serve as the basis for the system's defense against stressors. To maintain wellness, nurses strive to retain, attain, and maintain client system stability through primary, secondary, and tertiary interventions, with a focus on client defenses and the variables that constitute them, including spirituality. Neuman43 views the variable of spirituality on a continuum from dormant to positive system influence, emphasizing the potential impact of spirituality attended to by nurses.

Roy44 in the Roy Adaptation Model defines the person as a complex adaptive system presented with stimuli through environmental interactions. The person in Roy's model utilizes 4 adaptive modes in order to respond to environmental stimuli and reach adaptation or health. The adaptive modes include interdependence, physiological, role-function, and self-concept. The spiritual nature of the person and thus the spiritual focus of nursing are found in Roy's self-concept mode inclusive of moral-ethical-spiritual aspects and the interdependence mode of receiving and giving love.44

Dossey45 in the Theory of Integral Nursing presents a holistic and integral perspective of nursing and humanness inclusive of the spiritual dimension of experience and self. Spirituality can be found throughout the theory but most explicitly in descriptions of healing, nurse, and the interior experiences of the “I” perspective of reality.45 Nurses as integrally informed instruments of healing facilitate individuals toward achieving health. Health is described as an evolved higher consciousness of personal and collective understanding of physical, mental, emotional, and spiritual dimensions.45 Essential to the nurse's participation in integral nursing is the development of “I” or the interior experience, including a focus on personal spiritual maturity.45

Malinski46 presents a discussion on spirituality within Roger's Science of Unitary Human Beings. Roger's Science of Unitary Human Beings is guided by 4 major concepts, energy field, universe of open systems, pattern, and pandimensionality, and 3 principles of homeodynamics: helicy, resonancy, and integrality. Central to Malinski's46 discussion of spirituality in Rogerian Science is integrality. Integrality has been described as the context of the unitary human being in the life process, such that the human field is in continuous, evolving, and unitary relationship with the environmental field. Spirituality from a Rogerian perspective is identified by Malinski as:

pandimensional awareness of the mutual human/environmental field process (integrality) is a manifestation of higher frequency patterning (resonancy) associated with innovative, increasingly creative and diverse (helicy) experiences reflective of what is called spirituality in the literature.46 (p17)

Contemporary and ongoing, Watson's writings32 , 47 and interpretations of human caring, and caring science as sacred science, are perhaps the most elaborate body of theoretical work on spiritual nursing. Specifically, as reflected in certain of the Watson caritas processes (CP), nurses are called into practicing loving-kindness and equanimity (CP no. 1), sustaining self/other deep belief system (CP no. 2), developing/cultivating one's own spiritual practices (CP no. 3), creating healing environments (CP no. 8), and opening/attending to spiritual-mysterious/allowing miracle (CP no. 10).

Spiritual knowing is hinted at, although not explicitly named as such, in existing nursing literature referencing personal knowing. Carper,15 in the original 1978 piece, indicated that personal knowing “is concerned with the kind of knowing that promotes wholeness and integrity in the personal encounter, the achievement of engagement rather than detachment.”(p18) The essence of personal knowing is on knowing the self and knowing the other to be in relationship, or the notion of “reciprocity” or the “I-Thou” encounter.15 Furthermore, Watson,32 in her version of transpersonal relationality, describes the nurse who is able to develop authentic caring-healing relationships, going beyond the ego-self. This perspective helps further our explication of spiritual knowing as distinct from personal knowing. The need for transpersonal relations is clearly advanced in the work by Watson.32 Watson emphasizes the importance of the therapeutic use of self in the transpersonal relationship.32 Knowledge of self is essential to building an authentic relationship with the other. While this is affirmed in Carper's notion of personal knowing, Watson extends the personal to include the spiritual self. However, as described previously, our explication of spiritual knowing is distinct from Watson's notion of the spiritual self.

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SPIRITUAL KNOWING FOR NURSING PRACTICE, EDUCATION, AND RESEARCH

Nursing's multiple ways of knowing shape nursing practice, education, and research. Given our primary orientation to practice as a profession, we define spiritual knowing for nursing practice. Spiritual knowing for nursing practice is defined in relation to the more general description of spiritual knowing. We define spiritual knowing for nursing practice as nurses' awareness and intentional perceptual shift when providing human care from a focus on the body physical to nonmaterial spiritual qualities and experiences. As described earlier, such qualities and experiences facilitate meaning, healing, and sense of well-being, including, but not limited to, patience, gentleness, compassion, hope, forgiveness, humility, gratitude, unity, connection to a greater reality, and love. Perceptual means “relating to the ability to interpret or become aware of something through the senses.”48

The nurse embodies spiritual knowing for nursing practice in harmonious resonance with spiritual qualities and experiences. The nurse, in order to promote well-being, incorporates spiritual caring-healing modalities when drawing upon spiritual knowing. In the overall gestalt of multiple ways of knowing in nursing, the nurse practices from spiritual knowing that intersects with the other ways of knowing—empirical, personal, ethical, aesthetic, sociopolitical, emancipatory, unknowing. Spiritual knowing for nursing practice is necessary for nursing holistic human beings. Throughout the explication, the definition of spiritual knowing for nursing practice reflects the meta-paradigm in its current extant form—person/human being, environment, health, and nursing.1

Spiritual knowing for nursing practice promotes a well-being resource and advances the goals of the discipline. These goals are widely understood to promote health and healing, alleviate suffering, and prevent disease/injury. Spiritual knowing for nursing practice is congruent with central disciplinary foci: health, transitions, well-being, caring, wholeness, consciousness, patterning, humanness, and facilitating humanization, meaning, choice, quality of life, and healing in living and dying.7 , 9–14 Spiritual knowing for nursing practice honors holistic human beings within the context of their environments, recognizing them in their wholeness. Spiritual knowing for nursing practice involves cultivating spiritual caring-healing environments reflecting spiritual qualities.

In the realm of education, nursing academic programs emphasize care of holistic human beings and their environments. Therefore, it is critical to educate students and nurses about the multiple patterns of knowing in nursing. As stated by Carper,15 “understanding these patterns is essential for the teaching and learning of nursing.” Named patterns of knowing in nursing create a background for evaluating relevant knowledge for nursing education and practice. Along with the other patterns, we advance spiritual knowing as a necessary component of professional nursing education. As discussed earlier, more than 1 extant nursing conceptual model or theory posits human beings including a spiritual dimension. While students of professional nursing are exposed to a broad range of nursing and health sciences knowledge, multiple patterns of knowing in nursing, nursing concepts, and nursing theories should be a key hallmark of 21st century nursing education at the undergraduate and graduate levels. Current practice environments are also influential in nurses' professional education preparation. Accrediting bodies such as The Joint Commission mandate the provision of spiritual care in hospital settings. Despite this, research indicates that nurses consistently report being unprepared to provide spiritual care.36 This research points to the need for nursing educators to do a better job at preparing nursing students/nurses for the spiritual nature of human beings in health and illness situations. We envision nursing education including coursework or specific courses in spiritual knowing and spiritual aspects of nursing and healing at both the undergraduate and graduate levels, including spiritual care educational strategies and evaluation.

Finally, spiritual knowing as a pattern of knowing in nursing helps focus research priorities in nursing science. Current publication trends demonstrate an increase in articles focused on spirituality and spiritual care in nursing. New and innovative spiritual knowing–focused research is both needed and essential to informing national research priorities such as those proposed by the National Institute of Nursing Research. In particular, the National Institute of Nursing Research focus on end of life and palliative care can be further advanced through research that draws upon spiritual knowing as a pattern of knowing in nursing. For example, leaders in palliative care research identify spiritually informed research priorities such as spiritual assessment and screening and the development of spiritual care interventions.49 We propose that additional research is needed to continue to build spiritual knowledge for practice including assessment, spir-itual healing modalities, interventions, and outcomes.

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CONCLUSION

In this article, we have explicated spiritual knowing as a distinct pattern of knowing in nursing. Spiritual knowing is different from the meta-paradigm concepts, definitions of “spirituality” in extant conceptual models and theories, and the other patterns of knowing (empirics, personal, ethics, aesthetics, sociopolitical, emancipatory, unknowing).

Spiritual knowing is a central and necessary pattern of knowing in nursing that is essential for grasping/sensing/knowing the whole human being and environment in mutual process. Reflecting back to Carper's15 view in her 1978 essay, we end the article by asking: Is it still true that the patterns of knowing identified then, as well as those that have followed as discussed in this article, represent an evolving view of the whole that conditions how we approach the unique problems and questions pertinent to the discipline of the nursing? To this critical question, we answer Yes! As we travel onward in our discipline, we need to embrace our unique central unifying focus and purposeful vision.4 , 5 We call for continuing scholarly conversation about our syntax and substance, reflection on enduring and new disciplinary questions, and further explication of spiritual knowing as a pattern of knowing in the discipline. Spiritual knowing has been posited as having direct relevance to our understanding of human and environmental health and universal well-being from a nursing perspective. It is critical that we respond to the wake-up call that is implicit/explicit within this article as reflected in our writing, various questions, and description of spiritual knowing. Specifically, in relation to nursing's long-held value of attending to the spiritual nature of human beings, the appearance of new disciplines, such as the emergence of health care chaplaincy as referenced by Parse,50 places us at risk in the profession of further de-evolution, similar to the risks of uncritical allegiance and movement into interdisciplinarity. As Parse50 stated, “Is the emergence of a new discipline a wake-up call for nurse leaders and nurses to capture the opportunity to set the focus of nurses again on the whole person, including consideration of the individual's meaning and purpose in life? Who will answer the call to preserve the uniqueness of nursing as a discipline?”(p301)

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Keywords:

discipline; nursing; nursing knowledge; pattern of knowing; spiritual knowing; spirituality

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