Five Ways of Knowing One Patient: A Reflection on Caring for a Woman Who Declined Blood, and the Research Question It Raised
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Master of Science in Nursing Program, Aspen University
N508: Theory and Research
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Five Ways of Knowing One Patient: A Reflection on Caring for a Woman Who Declined Blood, and the Research Question It Raised
Barbara Carper argued that nursing draws on more than one kind of knowledge. In a landmark analysis of the nursing literature, she identified four fundamental patterns of knowing: empirical knowledge, the science of nursing; aesthetic knowledge, the art of nursing; personal knowledge, the nurse's self-understanding in relationship with patients; and ethical knowledge, moral judgment about what ought to be done (Carper, 1978). Later scholars added a fifth, sociopolitical knowing, which attends to the social, political, and institutional context in which care takes place (White, 1995). This paper reflects on a single patient encounter through all five patterns and then describes the nursing research interest that grew out of it. The patient is described as a composite, with details changed to protect privacy.
The Encounter
Mrs. D. was a 64-year-old retired bookkeeper admitted to our medical unit after a bleeding gastric ulcer. The bleeding had been controlled endoscopically, but her hemoglobin on my first night caring for her was 6.8 g/dL, down from 12 before the bleed. She was pale, short of breath walking to the bathroom, and her heart rate rose to 118 when she stood. She was a Jehovah's Witness and carried a signed advance directive declining transfusion of blood and its primary components.
The resident, new to the unit, was frustrated. He told me in the hallway that she was "going to die over a technicality" and asked me to talk her into accepting blood. I felt his urgency, and part of me shared it. I also sensed, as I sat with Mrs. D., that she had been asked the same question several times that day and was bracing for another argument. She said quietly, "I know what I am choosing. I just need someone to help me get through the night."
Empirical Knowing
Empirical knowledge told me what her body was doing and what could help. Her tachycardia on standing, dyspnea on exertion, and pallor were consistent with symptomatic anemia and reduced oxygen-carrying capacity. It also told me that her hemoglobin, although low, was not by itself an automatic trigger for transfusion even in patients who accept blood. A Cochrane review of 48 trials involving more than 21,000 participants found that restrictive transfusion strategies, most using thresholds between 7 and 8 g/dL, reduced the risk of receiving any red cell transfusion by 41 percent without increasing 30-day mortality or other major complications compared with liberal strategies (Carson et al., 2021).
That evidence reframed the situation. Mrs. D. was near the thresholds used in restrictive strategies, and her management would focus on what the evidence and her beliefs both allowed: preventing further bleeding, minimizing oxygen demand, supporting her own red cell production with intravenous iron and other agents the team discussed with her, and limiting blood loss from our own actions. When I reviewed her orders, I found laboratory draws scheduled every six hours, each using standard-volume tubes. Over several days, those draws would remove a meaningful volume of blood from a patient who had little to spare.
Ethical Knowing
Ethical knowledge concerned what I ought to do. Mrs. D. was an adult with decision-making capacity who had documented her wishes in advance, and her refusal rested on deeply held religious beliefs. Respect for autonomy meant honoring her decision, not wearing it down. Beneficence and nonmaleficence meant doing everything else possible to protect her. The ethical conflict was not really between the nurse and the patient; it was between the resident's understandable desire to save her life by one means and her right to decide which means were acceptable. My role was to advocate for her decision, to make sure the team knew about the hospital's liaison resources and bloodless medicine options, and to ensure that no one mistook repeated persuasion for good care.
Personal Knowing
Personal knowledge required me to be honest about my own reaction. I was raised to see blood transfusion as an ordinary, life-saving treatment, and my first internal response to Mrs. D.'s refusal was something close to impatience. Recognizing that reaction, rather than acting on it, was the first step toward being fully present with her. Once I set it aside, I could hear what she was asking for: not a debate but companionship through a frightening night. Carper (1978) described personal knowing as the nurse's capacity to know the self in order to relate authentically to others, and in this encounter it was the difference between another hallway argument and a genuine therapeutic relationship.
Aesthetic Knowing
Aesthetic knowledge is the art of perceiving what a particular moment requires and responding to it as a whole. With Mrs. D., it meant noticing that she was exhausted by argument and that what would help most was calm, practical care. I clustered her care so she could rest, arranged oxygen, helped her to the commode rather than the bathroom to reduce exertion, and asked the resident whether some of the overnight laboratory draws could be consolidated. At 3 a.m. she asked me to sit with her while she prayed, and I did. None of these actions appears in a protocol, yet together they shaped a night in which she felt cared for rather than contested.
Sociopolitical Knowing
Sociopolitical knowing asks how institutions, policies, and social positions shape care (White, 1995). Mrs. D.'s experience was shaped by a hospital culture that treated transfusion as the default and refusal as a problem to be solved, by a resident who had not been taught about bloodless medicine, and by laboratory routines designed without attention to cumulative blood loss. Her religious minority status meant that her values were often framed as an obstacle. Nurses have the standing to change such contexts: by requesting ethics or liaison consultation, by educating colleagues, and by questioning routines, such as frequent standard-volume blood draws, that quietly work against patients like her.
How the Patterns Worked Together
Carper presented the patterns as distinct, but the encounter showed how much they depend on one another. Empirical knowledge alone would have produced a correct but incomplete plan: monitor vital signs, give iron, watch the hemoglobin. Ethical knowledge alone might have produced a principled defense of her choice without the practical steps that kept her safe. My personal knowing, recognizing my own bias, made it possible to listen, and the aesthetic knowing that followed turned what I heard into a night of care that fit her. Sociopolitical knowing explained why the situation had become tense in the first place.
The integration also exposed a gap. My empirical knowledge of transfusion thresholds was solid, but my knowledge of bloodless medicine strategies and of how much blood routine testing removes was thin. I had to ask the pharmacist and look up the hospital's policy that night. Reflection on practice, as Carper's framework invites, is valuable precisely because it reveals where knowledge in one pattern is weaker than in the others, and that is where the research interest described below began.
A Research Area of Interest
The encounter led me to a research interest in patient blood management, particularly in reducing iatrogenic blood loss from diagnostic testing. Frequent phlebotomy contributes to hospital-acquired anemia, and every milliliter matters for patients who decline transfusion and for many who do not. Evidence on simple interventions is emerging. In a large stepped-wedge trial in intensive care units, switching from standard-volume to small-volume blood collection tubes did not significantly reduce transfusions in the primary analysis, although a prespecified secondary analysis suggested a modest reduction, and the smaller tubes rarely produced insufficient samples for testing (Siegal et al., 2023).
That mixed result points to questions nursing research could address on general medical units, where most patients are not critically ill but many are anemic: how much blood is drawn during a typical admission, how much of it is clinically necessary, and whether nurse-led review of standing laboratory orders, combined with small-volume tubes, reduces hospital-acquired anemia. A possible research question is: Among adults admitted to medical units, does a nurse-led laboratory stewardship protocol reduce the decline in hemoglobin from admission to discharge compared with usual practice? Answering it would draw on all five patterns of knowing: empirical measurement, ethical attention to patients' values, personal and aesthetic attention to how testing feels to patients, and sociopolitical attention to the routines that shape care.
Conclusion
Mrs. D. did well. Her bleeding did not recur, her hemoglobin stabilized, and she was discharged with oral iron and follow-up. Looking back, her care required every pattern of knowing: evidence to understand her anemia and her options, ethical judgment to protect her choice, self-awareness to set aside my own assumptions, the art of reading what a frightened patient needed at 3 a.m., and awareness of the institutional habits that worked against her. The encounter also gave me a research question that began at her bedside. Carper's framework explains why that is not a coincidence: in nursing, the questions worth studying often come from paying close attention to one patient.
References
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
Carson, J. L., Stanworth, S. J., Dennis, J. A., Trivella, M., Roubinian, N., Fergusson, D. A., Triulzi, D., Dorée, C., & Hébert, P. C. (2021). Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database of Systematic Reviews, (12), Article CD002042. https://doi.org/10.1002/14651858.CD002042.pub5
Siegal, D. M., Belley-Côté, E. P., Lee, S. F., Hill, S., D'Aragon, F., Zarychanski, R., Rochwerg, B., Chassé, M., Binnie, A., Honarmand, K., Lauzier, F., Ball, I., Al-Hazzani, W., Archambault, P., Duan, E., Khwaja, K., Lellouche, F., Lysecki, P., Marquis, F., ... Connolly, S. J. (2023). Small-volume blood collection tubes to reduce transfusions in intensive care: The STRATUS randomized clinical trial. JAMA, 330(19), 1872-1881. https://doi.org/10.1001/jama.2023.20820
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 N 508 Module 1 example is structured
N508 Module 1 typically asks you to reflect on a patient care encounter from your own practice using Carper's ways of knowing and to identify a nursing research area of interest, in 1,500 to 2,000 words with at least two scholarly sources beyond the textbook. Aspen revises courses, so follow your classroom's instructions. This example defines each pattern from the original sources, gives each its own section anchored in specific details of the encounter, and derives a researchable question from something the reflection actually noticed.
N508 Module 1 questions, answered
What does N508 Module 1 usually ask for?
Commonly a reflective paper of 1,500 to 2,000 words applying Carper's patterns of knowing to a patient care encounter from your practice and identifying a nursing research area of interest, with at least two scholarly sources plus the textbook and course materials.
What are Carper's ways of knowing?
Empirical (the science of nursing), aesthetic (the art of nursing), personal (self-knowledge in relationship with patients) and ethical (moral knowledge). Later scholars added sociopolitical knowing, and some texts add emancipatory knowing. The sample uses Carper's four plus White's sociopolitical pattern.
How do I connect the reflection to a research interest?
Look for a question the encounter raised that the evidence has not fully answered. In the sample, noticing frequent blood draws for an anemic patient leads to a research interest in reducing iatrogenic blood loss, supported by a trial with mixed results and ending in a specific research question.
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