Five Kinds of Evidence for One Question: Patterns of Knowing and the Withdrawal of Antipsychotics From Nursing Home Residents With Dementia
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Doctor of Nursing Practice Program, Aspen University
DNP845: Theoretical and Scientific Underpinnings
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Month Day, Year
Five Kinds of Evidence for One Question: Patterns of Knowing and the Withdrawal of Antipsychotics From Nursing Home Residents With Dementia
Doctoral nursing practice rests on evidence, but nursing has long recognized that evidence takes more than one form. Carper's fundamental patterns of knowing, later extended to include sociopolitical knowing, describe the different kinds of knowledge nurses use in practice. This paper applies those patterns to a doctoral practice question, whether antipsychotic medications can be safely withdrawn from nursing home residents with dementia, and argues that a DNP-prepared nurse needs all of them to answer it well.
The Practice Question
In a composite 140-bed nursing home, 22 percent of residents with dementia receive an antipsychotic, most prescribed for agitation or aggression years earlier, often in a hospital. Nurses describe residents who are quiet but withdrawn, and families who were never told of the risks. The DNP student's question is whether a structured, nurse-led review and withdrawal program can reduce antipsychotic use without worsening behavior or quality of life.
Empirical Knowing
Carper (1978) described empirics as the science of nursing: knowledge that is systematically organized into general laws and theories and that can be verified through research. For this question, empirical knowledge includes trial evidence. In the dementia antipsychotic withdrawal trial, residents of care facilities randomized to continue antipsychotics had a 12-month survival of 70 percent compared with 77 percent for those switched to placebo, and the survival difference grew over longer follow-up (Ballard et al., 2009). Empirical knowing tells the DNP student that continued use carries risk and that withdrawal is often possible.
But empirical knowledge is general. It describes average effects across groups and cannot say which resident will become distressed when a medication is stopped.
Aesthetic Knowing
Carper (1978) called aesthetics the art of nursing: the nurse's perception of the particular, the ability to grasp what is significant in a patient's behavior and to design care that fits the whole situation. In this setting, aesthetic knowing is the experienced aide's recognition that a resident becomes agitated at 4 p.m. because the light changes and she believes she must go home to her children. It is the nurse who notices that a resident strikes out only during showers. This knowledge suggests nonpharmacologic responses, such as changing bathing routines or offering a meaningful task in the late afternoon, that make withdrawal possible for that resident.
Personal Knowing
Personal knowing concerns the nurse's knowledge of self and the authentic relationship with the patient (Carper, 1978). A nurse who has seen a resident injure a staff member may hesitate to support withdrawal. Recognizing that fear, and distinguishing it from evidence, is part of personal knowing. So is the ability to be present with a distressed resident without reaching first for a medication. For the DNP student, personal knowing also means acknowledging that the project challenges prescribing habits in which nurses have participated.
Ethical Knowing
Ethical knowing is knowledge of what ought to be done, based on moral principles and obligations (Carper, 1978). Antipsychotics used to manage behavior can function as chemical restraint, limiting a resident's freedom and alertness for the convenience of care. At the same time, withdrawing a medication that controls genuinely distressing psychosis could cause suffering. Ethical knowing requires weighing these obligations for each resident and ensuring that residents' surrogates are informed of risks and participate in decisions, a step often skipped when the medication was started.
Sociopolitical Knowing
White (1995) argued that Carper's patterns overlook the context in which nursing takes place and added sociopolitical knowing: understanding the social, political, and economic forces that shape health and care. Antipsychotic use in nursing homes is shaped by staffing levels, since agitated residents require more staff time, by regulatory attention to antipsychotic rates as a quality measure, and by payment systems. A withdrawal program will fail if it asks overstretched aides to replace a pill with an hour of individualized attention they do not have. Sociopolitical knowing tells the DNP student that staffing and policy are part of the intervention, not background to it.
Integrating the Patterns
No single pattern answers the question. Empirical knowing shows that withdrawal is usually safe and continued use is harmful on average. Aesthetic and personal knowing identify which residents need individualized alternatives and help staff manage their own fears. Ethical knowing frames the decision as a matter of rights and informed consent. Sociopolitical knowing identifies the staffing and policy conditions the program needs. The DNP student's project therefore combines a pharmacist-supported medication review, behavioral care plans developed with direct care staff, family conferences, and a staffing plan for the late-afternoon hours when agitation peaks.
This integration reflects what distinguishes the DNP role: translating empirical evidence into practice in a way that respects the other forms of knowledge that determine whether practice changes.
Limits of the Framework
The patterns have limits of their own. They overlap in practice, and treating them as separate boxes can hide how an aide's perception of a resident is shaped by ethical commitment and personal experience all at once. A second danger is that empirical knowing is treated as the only real evidence and the others as soft additions. Chinn and Kramer (2018) respond by adding emancipatory knowing, the capacity to notice social and structural injustice and to act to change it, and by describing how each pattern is developed and checked through its own processes rather than judged by the standards of research. For this project, emancipatory knowing asks why antipsychotic use has been tolerated for residents who cannot object, and whether residents of facilities with fewer resources receive these medications more often. That question moves the DNP student from improving one facility to asking what policy would protect residents everywhere.
Conclusion
The patterns of knowing are not a historical curiosity but a practical guide to what counts as evidence in doctoral nursing practice. For the question of withdrawing antipsychotics from residents with dementia, trial data are necessary but not sufficient. The perception of experienced staff, the self-awareness of nurses, ethical judgment, and an understanding of staffing and policy all shape whether the evidence can change care. A DNP-prepared nurse draws on all of them.
References
Ballard, C., Hanney, M. L., Theodoulou, M., Douglas, S., McShane, R., Kossakowski, K., Gill, R., Juszczak, E., Yu, L.-M., & Jacoby, R. (2009). The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomised placebo-controlled trial. The Lancet Neurology, 8(2), 151-157. https://doi.org/10.1016/S1474-4422(08)70295-3
Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13-24. https://doi.org/10.1097/00012272-197810000-00004
Chinn, P. L., & Kramer, M. K. (2018). Knowledge development in nursing: Theory and process (10th ed.). Elsevier.
White, J. (1995). Patterns of knowing: Review, critique, and update. Advances in Nursing Science, 17(4), 73-86. https://doi.org/10.1097/00012272-199506000-00007
How this DNP 845 Module 1 example is structured
DNP845 Module 1 often opens on ways of knowing and what counts as nursing evidence. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example defines each pattern from the original sources, applies each to one doctoral practice question, shows its limits and integrates them into the design of a project.
DNP845 Module 1 questions, answered
What does DNP845 Module 1 usually ask for?
The first module often explores ways of knowing in nursing and what counts as evidence, asking you to apply a framework such as Carper's patterns of knowing to a practice question. Aspen does not publish module deliverables, so your classroom's instructions govern.
What are Carper's patterns of knowing?
Empirical knowing, the science of nursing; aesthetic knowing, the art of perceiving and responding to the particular situation; personal knowing, self-knowledge and authentic relationship; and ethical knowing, knowledge of what ought to be done.
What did White add to Carper's patterns?
Sociopolitical knowing: understanding the social, political and economic context of care, such as staffing, policy and payment, which shapes whether nursing knowledge can be applied.
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