Running head: WAYS OF KNOWING IN A CLINICAL CASE 1

Ways of Knowing in a Clinical Case

Karen Fugate

University of Central Florida

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Ways of Knowing in a Clinical Case

Carper’s Ways of Knowing encompass four patterns of knowing in nursing: empirical

knowledge, esthetic knowledge, personal knowledge, and ethical knowledge. According to

McEwen and Wills (2011), all are essential to the “whole” of nursing (p. 17). They form the

body of knowledge which is the foundation for nursing practice. Nursing care of the infant with

Neonatal Abstinence Syndrome (NAS) can pose many challenges. The following case

presentation describes clinical practice problems related to the care of an infant with Neonatal

Abstinence Syndrome (NAS) and the multiple ways of knowing employed to resolve the

problems. The names are fictitious to protect the privacy of the infant and mother.

Clinical Practice Problem

Katy, a full term female infant, was transferred to the Neonatal Intensive Care Unit

(NICU) from normal newborn on day of life two for management of NAS. Katy had a Finnegan

score of twelve upon transfer. The Finnegan score is an objective measurement tool used to

quantify the severity of withdrawal symptoms in the neonate (Hudak & Tan, 2012). The

Finnegan score is comprised of scoring sections for central nervous system,

metabolic/respiratory, and gastrointestinal symptoms (Sublett, 2013). Katy’s elevated score was

primarily attributed to central nervous system symptomology including irritability, tremors,

increased muscle tone, excessive sucking, poor feeding, interrupted sleep-wake cycle, and

exaggerated Moro reflex.

Katy’s mother, Missy, was a twenty-eight year old first-time mother with a history of

oxycodone addiction. Missy sought treatment for her addiction when she found out she was

pregnant because she did not “want to harm her baby”. Missy was prescribed methadone to

replace oxycodone to avoid detoxification during her pregnancy which is associated with fetal
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distress and increased fetal loss (Hudak & Tan, 2012). Missy was compliant with her treatment

plan. Her urine drug screen was negative at delivery with the exception of methadone. Missy was

distraught during her visits and would frequently cry and leave the room when she could not

console her baby. She voiced she thought her baby would be “fine” because she switched to

methadone during her pregnancy. Social work had been consulted and had cleared Katy for

discharge to her mother when medically cleared.

Katy’s care involved administering methadone by mouth as pharmacologic treatment for

her withdrawal and Finnegan scoring to determine therapeutic response. Non-pharmacologic

treatment included swaddling, decreased environmental stimuli and handling, pacifier use, and

gentle rocking. Non-pharmacologic interventions were based on Katy’s cues as no one or

combination of interventions seemed to work consistently. Katy was difficult to feed and

required swaddling, frequent rest periods, and decreased environmental stimuli during feeds to

be able to consume sufficient volume for growth. Katy was fed “on-demand” so it was critical to

be able to discern between excessive sucking associated with withdrawal and genuine hunger

cues.

Although Katy was the patient, nursing care also had to be provided for Missy so she

would be able to assume the role of primary caregiver at discharge. Missy was educated on

recognition and management of Katy’s withdrawal symptoms to include feeding and soothing

techniques and parental coping strategies. She was encouraged to spend time with her daughter

so she would feel confident in her parenting ability. Missy was treated as a parent first and not a

person with a substance abuse problem. Communication with Katy was facilitated by providing a

non-judgmental environment where she was comfortable asking questions and voicing her

worries, fears, and concerns.

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Application of Ways of Knowing in the Solution

Empirical Knowledge

Carper (1978) describes empirical knowledge as the science of nursing where knowledge

describes, explains, and predicts “phenomena of special concern to the discipline of nursing” (p.

14). White (1995) updates the original model by adding the dimension of what is learned from

facts, theories, and models described in books and professional journals. Examples of use of

empirical knowledge in the nursing care provided in this case scenario are many. I safely

administered methadone and scored the Finnegan tool correctly based on very specific guidelines

providing a reliable assessment of reaction to interventions (Hudak & Tan, 2012). I

experimented with various non-pharmacologic care measures known to be effective in

ameliorating withdrawal symptoms including modification of the environment, rocking, pacifier

use, and small, frequent feeds (Sublett, 2013). I encouraged maternal involvement in care which

has also been found to be beneficial in this patient population. A meta-analysis conducted by

Suchman, Pajulo, DeCoste and Mayes (2006) found that the only interventions associated with

successful parenting in drug-dependent mothers focused on attachment behaviors, strong

relationships between nurse and mother, and encouraging mothers to recognize behavioral cues

of their infant.

Esthetic Knowledge

Carper (1978) describes esthetic knowledge as the “art of nursing” and the ability of the

nurse to perceive the “need that is actually being expressed by the behavior” (p. 17). White

(1995) describes this as intuition. The ability to perceive (or intuit) the needs of patients requires

the nurse to be empathetic; the more skilled the nurse becomes at empathizing, the more

understanding will be gained from the interaction and the nurse will be able to design effective
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care (Carper, 1978). White also noted that context-specific experience is important to esthetic

practice. Empathy and perception were utilized to determine that Missy was distraught. I

attempted to create a therapeutic, non-judgmental relationship in which Missy felt comfortable

voicing her fears, concerns, and worries. Many years of experience as a neonatal intensive care

nurse and specific experience with NAS infants and their families was beneficial in developing

effective communication strategies to facilitate this relationship. The relevance of esthetic

knowledge when caring for neonates cannot be overstated; neonates are non-verbal so

interventions are founded on observed behavior and nurse perceptions based on experience and

intuition. Extensive experience caring for the infant with NAS allowed me accurately interpret

Katy’s behavioral cues in response to various interventions contributing to a developmentally

appropriate, individualized approach to care.

Personal Knowledge

Carper (1978) describes personal knowledge as the ability of the nurse to incorporate

“therapeutic use of self” to develop an authentic patient-client relationship whereby the patient is

accepted as a unique individual. White (1995) further illuminates personal knowledge as the

humanity or openness of the patient-client relationship without which “nursing is only technical

assistance, not involved care” (p. 80). I accepted Missy as a unique individual and approached

her in a non-judgmental manner. It is so easy to judge the drug-dependent mother and I have

seen the detrimental results of this approach many times. If I had judged Missy, the therapeutic

relationship would have been compromised and Missy would not have been receptive to teaching

and learning the skills necessary to care for Katy.

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Ethical Knowledge

Ethical knowledge, per Carper (1975), is the moral code which guides the ethical conduct

of nurses and is focused on the “obligation of what ought to be done” (p. 20). The National

Association of Neonatal Nurses (NANN) Code of Ethics states: “The worth, integrity, dignity,

uniqueness and human rights of patients, employers, colleagues, students, employees, parents

and families of the infant will be respected regardless of ethnicity, gender, social/economic status

or physical or mental challenges” (National Association of Neonatal Nurses website, n.d.).

Therefore, treating the drug-dependent mother with dignity and respect is ethically “what ought

to be done”. I was able to maintain my moral integrity despite being faced with the moral

conflict of providing guidance and support for a mother whose lifestyle choices had caused such

suffering in her infant. I couldn’t help but wonder if Missy would be able to parent Katy after

discharge with twenty-four hour a day responsibility. Would Missy be able to handle the

stressors of everyday life, her addiction, and a demanding baby? Would Katy be abused or

neglected? As a nurse, I wanted to protect Katy but realized Missy was the one who would be

taking her home. After all, Missy was Katy’s parent. By recognizing my feelings, I was able to

make a conscious effort to develop a meaningful, therapeutic relationship with Missy giving her

the best chance to be a successful parent which in turn would positively affect Katy’s outcomes.

Sociopolitical Knowledge

Sociopolitical knowing, per White (1995) addresses the “wherein” of nursing or

the “broader context in which nursing and healthcare take place” (p. 83). Drug dependence,

according to White, is a political problem as well as a personal problem. In this case, it is

important to understand that drug dependence is many times a human response to the stressors of

society. Many substance abusing mothers have histories of sexual abuse, domestic violence, and
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underlying mental illness and they are self-medicating as a coping mechanism (Catlin, 2012).

Fortunately, for Missy and Katy’s sake, the Tampa area has opioid dependency treatment centers

specifically designed to care for pregnant women. Mothers receive medication treatment,

counselling, and parenting classes. Healthy Start also offers intensive services to this population

both during pregnancy and after discharge. It is imperative that nursing be aware of these

services so that they are able to make referrals. Nursing is advocating for this vulnerable

population on a national level as well. The American Nurses Association published a position

paper titled “Non-Punitive Alcohol and Drug Treatment for Pregnant and Breastfeeding Women

and Their Exposed Children” advocating that nurses care equally for the infant and the mother

and connect them with needed services (Catlin, 2012). NANN is advocating for this population

also, calling to “extend our knowledge and advocacy to a population that needs us” (Catlin,

2012, p. 287); the “population” they refer to is the mother, not the infant.

Summary and Conclusions

Katy was discharged to her mother after a three week stay in the NICU. To my

knowledge, Katy was not readmitted so I can only hope that all went well. I hope I was able to

influence Missy in some small way. Caring for an infant with NAS and the substance-abusing

parent, although not technically challenging, poses one of the most difficult, demanding clinical

situations. The nurse must care for both the infant and the parent; each presenting the nurse with

a unique set of clinical problems. I was able to utilize all the “ways of knowing” to provide

comprehensive, therapeutic care for this dyad.

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References

Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science,

1(1), 13-23.

Catlin, A. (2012). Call for improved care for the substance-positive mother. Advances in

Neonatal Care, 12(5), 286-287. doi:10.1097/ANC.0b013e318267bb41

Hudak, M., & Tan, R. (2012). Neonatal drug withdrawal. Pediatrics, 129(2), e540-e560.

doi:10.1542/peds.2011-3212

McEwen, M., & Wills, E. M. (2011). Theoretical basis for nursing (3rd ed.). Philadelphia, PA:

Lippincott Williams & Wilkins.

National Association of Neonatal Nurses website. (n.d.). http://www.nann.org

Nelson, M. (2013). Neonatal abstinence syndrome: the nurse’s role. International Journal of

Childbirth Education, 28(1), 38-42.

Sublett, J. (2013). Neontal abstinence syndrome: Therapeutic interventions. The American

Journal of Maternal Child Nursing, 38(2), 102-109.

doi:10.1097/NMC.0b013e31826e978e

Suchman, N., Pajulo, M., DeCoste, C., & Mayes, L. (2006). Parenting interventions for drug

dependent mothers and their young children: The case for an attachment-based approach.

Family Relations, 55, 211-226. doi:10.1111/j.1741-3729.2006.00371.x

White, J. (1995). Patterns of knowing: Review, critique and update. Advances In Nursing

Science, 14(4), 73-86.