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Nursing Epistemology: Traditions, Insights, Questions Phyllis R. Schultz and Afaf I. Meleis Epistemology i the study of what human beings know, haw they come to know what they think they knew and what the rita are for evaluating knowledge claims. Nursing epistemology sth study of knowledge shared emang the mem bers ofthe discipline, the patcns of knowing and knoteedge that develops fom ‘them, and teeter for accepting krowldgeclaime, Three yes of kneeledge ‘specie to nursing asa discipline are described here: clinical knowledge, con eptual knowledge and empirical kncwledge. Diferent criteria for evaluating (ach pe ae suggested, ‘using epistemology is the study of the origins of nurs: ing knowledge, its structure and methods, the patterns ‘of knowing ofits members, and the erteria for valida: ing its knowledge claims, Just ax women are aware increasingly that their perceptions, observations and reasoning about the world contribute understandings that are unique, so too rurses, as members ofa discipline and profession made up mostly of women, are changing in consciousness as knowledge for and from the practice of nursing continues to grow. This paper explores the epistemology of nursing; it grows out of the belief that, a8 nurses, ‘our ways of knowing have not yet been fully articulated but that they will emerge if we allow ourselves to sce the world through the yes of practicing nurses and their cient, ‘The term “‘epistemology”” comes from philosophy, where it is defined as the study of knowledge, or theory of knowledge (Flew, 1984). As a practice discipline and profestion, nursing is often described as both an “art” and a “science.” Articulating ite episte- mology it therefore a complex task: The study of nursing know! edge must range from the seemingly intuitive “-knowing’” of the ‘experienced and expert nurses to the systematically verified knowl: ‘edge of empirical researchers, The epistemology of any field of inquiry depends on the nature of the phenomena studied and on the propensities of the inquirers who are developing knowledge in the field. ‘Nursing epiatemology, then, is the study of how nurses come to know what they think they know, what exactly nurses do know, how nursing knowledge is structured and on what basis knowledge claims are made. What is Knowing/What is Known? For any person, knowing begins with the processes of obterva- tion, perception and experience in encountering the world and Volume 20, Number 4, Winter 1988 being in the world. These processes give rite to describing and inter preting phenomena, including anticipating, with some degree of accuracy, what is likely to happen at some future time. Tt is helpful to think of “knowing” as a process and the knowledge that comes from that process as the product (Bencliel, 1987; Chinn & Jacobs, 1987) ‘According to Benoliel, “Knowing can be viewed as an indivi ual's perceptual awareness of the complexities of a particular situa tion and draws on inner knowledge resources that have been ga nnered through experience in living” (p. 181). It rarely can be expressed through discourse but is experienced through the acts of persons (Benner, 1983; Chinn & Jacobs, 1987). By contrast, know! fdge as product is often expressed in some form of communication such as informal conversations, formal oral presentations, written, articles and texts or art forms such as paintings, poetry, novels or In a practice discipline, knowing is also working on solutions to problems that are important for the welfare of clients, It includes the ability to identify the questions at the forefront of inquiry in the field, the issues involved in answering these questions, the Ways to go about answering the answerable questions and the ways to han dle the unanswerable questions. Knowing is aleo having the wisdom to recognize which questions have top priority, which are secondary and which are trivial; it is recognizing which questions can be answered in the near furure and which have to be deferred, In epistemology, Chisholm (1982) formulated the questions about knowing PHYLLIS R. SCHULTZ, RN, Ph.D, Alona Kappa, is Assistant Professor {at the University of Colorado Heath Scences Center, Schoo! of Nursing, Denver. AFAF I. MELEIS, RN. PhD, FAAN, Alpha Eta 6 Professor atthe University of California School of Nursing. San Fran: ‘seo. Correspondence to Box C-288, £200 East Ninth Avenue, Univer sity of Colorado Health Sciences Center, School oF Nursing, Denver, cosons2, Or. Schutz ratefuly acknowledges the opportunity to exolare with Dr. Meets several ideas on nursing enstemology during portdoctoral study at UCSF in Spring 1986 and 1987. This caper Is an adaptation of a Keynote address presented by Professor Melels at the Fourth “Annual Nursing Science Colloquium on Strategies for Theory Develop ‘ment in Nursing v, Philosophy oF Science ana the Develooment Nurs ing Science, Boston University School of Nursing, March 19-20, 1987, ‘Accepted for oubication February 17, 1988, 27 1, “What do we know? What isthe extent of our knowledge?” 2, “How are we to decide whether we know? What are the criteria ‘of knowledge?” (p. $0) Chisholm identified three epistemological positions a possible answers to these questions: skepticism, method fm and particulariem. Skeptics say that these are unanswerable questions because we cannot answer either set without presupposing fan answer to the other. This position is untenable for a practice dis- cipline beeatie we have to take care of real people with real health problen By ‘"methodism,”” Chisholm (1982) meant that to have know! ‘edge is to have a preferred method of inguiry and procedures for Fecognizing reliable oF credible knowledge (ie., one begins by answering the second set of questions (set 2). Chisholm explicitly identified empiriciem as a “type of ‘methodist’ ” (p. 67) ‘debates ia nursing about qualitative and quantitative daa col ‘with their corresponding metaphysical and epistemological founda: tions reflect a type of methodivi in nursing (Schultz, 1987). This Imethodism has led some nurse inguirers to subscribe to science in general and to empiricist science in particular as the preferable epis- {emological positon in nursing. “The allegiance to empiricism can explain some ofthe sense of sep- aration that has arisen among nurse inguirers who hold different epistemological positions and use different methods of inquiry Some rely on reflection and reasoning; others lect structured obser vation and hypothesis testing; still others prefer phenomenological dialogue and reflective interpretation. Academicians tend to insist fon knowledge that is formal, orderly, validated and communicable. Practitioners trust knoveledge that results in appropriate ations with clients in specific situations. To espouse the methodist’s epistemo- logical postion is to fail to recognize the legitimacy of these multi- ple ways of knowing; itis to resist accepting the complexity and holistic character of nursing (Benoliel, 1987; Chinn & Jacobs, 1987; Visintainer, 1986) By “particularism,"” Chisholm (1982) meant “We an know and nove that we know some particular thing at a particular point in ime” (p. 74). This position starts from the premise that there are tome things we know, whether or not we agree on the methods and procedures for knowing (Chisholm, 1982; Schultz, 1987). Philoso- phers begin with rather ordinary, everyday cates of knowledge such fs “I know how to drive a ear” and “T know that seven plus five Cquals twelve.” Similarly, “T know that the sentence, Some mush: rooms are poitonous, is true” (Lehrer, 1974). These three state- ments can be classed as (a) recounting a practical skill, (b) com- Imunicating a conceptual insight and (c) articulating an’ empirical hypothe ’As nurses, we begin with particular cates of knowledge from (a) ‘our practice, (b) our theories, or (¢) our research. Statements about What we “know” are reflected implicitly or explicitly in the writings of our clinicians, theorists and researchers, for example: 1, ‘The experiences of pertons in health and illness are revealed in characteristic patterns, These patterns tend to be repetitive, orderly, predictable, and unified; they rlleet organization 2. Some individuals have health and iliness experiences that do not fit the general pattern, Thus another case of what we “know” in nursing is that itis predictable that individuals may be unpredict- ale in thei health and illness experiences. 5. Human health and illness can be perceived and understood through uncovering the meanings that individuals, groups and soci= ties derive from their experiences. 44. The health and illness of persons are interactive with environ- 5. Nursing acts influence the responses of persons in health and ill- ness; nursing and the experiences of persons with health and illness ‘Statements such as these about what we “know” in nursing are what we want to begin with in formulating the criteria of knowledge in our discipline. But before we explore auch criteria, we will discuss patterns of knowing revealed in the nursing literature, and those from a study of women (Belenky eta, 1986), which may contribute 218 [Nutting Epistemology: Traditions, Init, Questions to our understanding of the types of knowledge in present-day nurs ing. Patterns of Knowing in Nursing ‘The complexity of nursing’s epistemology was clearly demon: strated by Carper's (1978) delineation of four fundamental patterns of knowing in nursing: empires, ethics, esthetics and personal Knowledge. Each of these four patterns has recently been specified epistemologically by Chinn and Jacobs (1987). Here we will elabo- rate only on personal knowledge, beeause of our belief in the impor- tance of the practitioner asthe knower in nursing’s development of knowledge, Personal knowledge was described by Carper (1978) as selF knowledge, or awareness of the self. This description seems to leave tout the knowledge from practice that Benner (1983) termed “prac fal knowledge," following the reasoning of Polanyi (1964) in his Pr- tonal Krowoledge. For Polanyi, “personal” referred to a characteristic of the knower; “knowledge,” co a mental process 1 regard knowing at an active comprehension of the things known, a faction that requires dill... Comprehension ie either an arbitrary Skinor a pasive experience, buts fesponnible act claiming universal valny ‘Thus to know the self is part of comprehending “the things known.” Knowing what one knows is also part of comprehending Polanyi (1964) distinguished between Knowledge as theory and knowledge as practical shill, He termed knovledge that may not be articulated through language as “tacit knowing"; knowledge chat is ‘communicable through discourse he termed ‘explicit knowing,” ‘Another way to phrase this distinction is “knowing how'” and “knowing that,” which Benner (1983) found useful in explaining what expert nurses know. Expert nurses may enter a caring encoun- ter with awareness of the self as therapeutic agent (Carper, 1978) and with a foundation of formal concepts, theories, facts and skills learned in their education (the knowing that). According to Benner (1903), as the encounter, or event, unfolds, they refine, elaborate or dlisconfirm this “foreknowledge”; the encounter then deserves to be termed “experience” and contributes to the knowing how. These three aspects of personal knowledge—knowing the self, knowing that and knowing how-—are the sum of what one knows” All three fare brought to the caring situation and are used to identify and solve the problems of the discipline ‘Unfortunately, we know very litle about personal knowing, espe cially about knowing the self and knowing how, in part because they tan only be articulated retrospectively (Chinn & Jacobs, 1987). The knowing how from practice may, however, be brought ¢o conscious ness and made ‘communicable through innovative methods of inquiry such as interpretive, grounded theory or phenomenological research (Benner, 1983; 1985; Pyles & Stern, 1983, Ray, 1987). For example, using ® grounded theory approach, Pyles’ and Stern described the “nursing gestalt," by which exper’ critical care nurses identify impending cardiogenic shock and prevent untimely death ‘They learned that novice nurses must work with expert critical care nurses (the Gray Gorilla concept) to acquire their know how for practice. Their findings corroborated those of Benner’s (1983) study fof the knowledge embedded in clinical practice Alto, in a study of critical care nursing using phenomenology a method, Ray (1987) discovered thatthe essence of nursing in critical care involves technological and ethical caring; itis an experiential ialectie between technical competence (doing no harm) and com passion (in response to sufering), which are mediated through ethi- fal choice (preserving autonomy and ensuring justice) Efforts to bring to consciousness the self-knowledge and knowing how of nursing practice may be aided by examination of women’s ways of knowing identified by Belenky et al. (1986). The patterns they discovered were not supposed to be hierarchical, although unfortunately their descriptions appear to be so. In applying their framework to nurses, we will artume that diffrent patterns of know= ing exist simultaneously. The five patterns of women’s knowing that IMAGE: Journal of Nursing Scholarship Nonsing Epistemology: Traditions, asighs, Queto [Belenky etal identified are silence, received knowledge, subjective knowedge, procedural knowledge and constructed knowledge, Each ofthe five patterns is explained in the following: Silene. Persons "experience themselves as mindless and voiceless and subject to the whims of external authority" (p.16). Belenky et Al. add that silent women know at the "gut level” but have not cule tivated their eapacity for abstract thought; nor do they attempt to articulate why they do what they do. They accept the voices of authority for direction in their work and life because of others’ power, not necessarily expertise. Others are ‘right the silent one is “wrong” and dumb." According to Colliere (1986) silent nurses may not know how to conceptualize their daily experiences; they follow the voices of others because of fear of others’ power. They do not have the language to {generalize from what they know so that their knowledge can be com: ‘municated. They have learned to be silent. Their work, their pat tems of knowing and their knowledge are invisible, Recived knowledge. Persons “perceive themselves as capable of receiving, even reproducing, knowledge from all-knowing external authorities but not capable of creating knowledge on their own” (p. 13). Individuals who use this way of knowing rely on others for the words to communicate what they know. For this type of knower, knowledge is observable; there is no ambiguity init, and it depends fn the expertise of others, Many nurses bave contented themselves with using the words of others to express and guide their knowing. American nurses have used medical knowledge, psychological and sociological knowledge, philosophical knowledge and administrative knowledge to comrnus niicate what they know. Following the same pattern, nurses in other countries have used nursing theories developed in the United States (communicate the nature of their practice Subjective iowledge. Knowledge is “conceived of as personal, pri- vate, and subjectively known and intuited" (p, 15). The subjective pattcrn of women’s knowing reminds us of the debates in nursing foday about the usefulness and reliability of experiential knowing (ice, knowledge from practice). Knowers such as this in nursing offer us their subjective wisdom from their own inner voices, which ‘may enhance our understanding of complex situations, but their knowledge is transient, and not cumulative. Such knowers may find ie dificult to articulate the processes that they have gone through in knowing because knowing for them is intuitive, experienced, not thought out and something felt rather than cognitively appraised or constructed ‘Procedural knowledge, These knowers depend on careful abserva- tion, structured procedures and systematic analyses. In short, they are rationalists. They use objectivity as a measure of what can be known as well a repeated observations under controlled situations for corroboration. ‘They distance themaclves from experience in order to know. Though they use subjective awareness to provide insights, they adhere to the idea that objectivity yields the know! crige that is most reliable, ‘Nurse researchers and academicians are the strongest adherents of this way of knowing. Following strict procedures for inquiry is considered the way to secure reliable knowledge for teaching the principles and practices of nursing and for further inquiry. Ax we ‘emphasize increasingly research-based practice, clinicians are join ing the ranks of the rational, procedural knowers in nursing. onstraced tnowiedge. A pattern of knowing in which persons “view all knowledge as contextual, experience themselves as ere ators of knowledge, and value both subjective and objective strate gies of knowing’ (p. 15). These knowers integrate the different ways of knowing and the differenc voices (including the silent voice). To them, “all knowledge is constructed, and the knower is an int smate part ofthe known'"(p. 37), Nurses who subscribe to this view of knowing see theories ax approximations of realty that are ongoing and always in process; their frames of reference are constructed and reconstructed (Visintaines, 1986), and posing questions is as important as attempting to answer questions, These nurses believe that knowing Volume 20, Number 4, Winter 1988 is achieved as much through openness and curiosity and through examination ofthe assumptions and context within which questions are posed as through adherence to procedures or systematic observa- tion and replication. For nurses who subscribe 1o this view of knowing, the develop: ment of knowledge is a never-ending process. There are glimmers of certain knowledge if one understands the whole of a. situation including formal knowledge of the phenomenon, Experts (i.e, expe: rienced knowers) develop a connected knowing through conversing with each other and through identifying pattern, consistencies and corder in the evidence provided by the various ways of knowing (Benoliel, 1987; Schultz, 1987). Their knowledge is corroborated by knowledge from other disciplines ‘Types of Nursing Knowledge and Criteria of Credibility From our reflections on the traditional patterns of knowing in nursing and on worncn’s ways of knowing, we have identified three types of knowledge specific to nursing as a discipline: clinical know- cdge, conceptual knowledge and empirical knowledge, Discussed below are their relationships co the diferent patterns of knowing and possible eiteria of eredibilty fo each type. Clinical Knowledge inical knowledge results from engaging in the gestalt of caring, from bringing to bear multiple ways of knowing in order to solve the problems of patient care. Florence Nightingale knew the needs of the soldiers who fought in the Crimean War because she worked with them day and might; she was able to see the results of limited resources and exposure tothe uahygienie environment, She realized that not only were diseases aflieting the soldiers, but the care they failed to receive affected thei recovery. Clinical knowledge is manifested primarily in the acts of practi ing nurses; i is incividval and perzonal. Historically, ic has often been voiceless except in descriptions of the art of nursing, which have come to be viewed as less important and eredible since nursing has been developing formal empirical foundations for practic. Cl niicians experience patients’ situations and “do!” (je., they act based on these experiences). Historically, clinical knowledge has been the product of s combi- nation of personal knowing and empirics, It has usually involved intuition and subjective knowing, although these have tended to be ignored, denigrated or denied (Rew & Barrow, 1987). In the past, the empirical base was often “received empiries” from medicine of the social and behavioral sciences. Increasingly, however, empirical studies by nurses inform clinical practice. Further, intuition and subjective knowing are regaining ther legitimacy as necessary com- ponents of humane care (Watson, 1985). The acathetic and ethical patterns of knowing are also contributing to the development of clin- ical knowledge in response to the changing needs of persons inter- acting with technological and organizational environments. Traditionally, clinical knowledge has been communicated retro- spectively, through the publication of articles on specific client prob- Jems. These accounts, in national journals of nursing and increas ingly in international journals, report individual case descriptions ot summaries of multiple cases that provide antwers for questions and problems in practice. These published accounts often reflect received knowledge and procedural knowledge and are character- ized by prescriptions for practic, The credibility of clinical knowledge has been based on the useful ‘ness of its communicated wisdom-—"Tt works.”” This criterion meets the requirement of purposefulness of a practice discipline (Chinn & Jacabs, 1987). De we nced other modes of corroboration? Can the art of nursing yield as reliable and reproducible knowledge a does the “science’” of nursing? Should it? Perhaps models of practice, the discovery of patterns within and across clients and tes timonials of subjective knowledge might be appropriate criteria for the credibility of clinical knowledge. These are unanswered ‘questions. 219 ‘Nursing Epistemology: Tradition, Insights, Questions Conceptual Knowledge Conceptual knovledge is abstracted and generalized beyond per- sonal experiences, itexplicates the patterns revealed in multiple cli- ‘ent experiences in multiple situations and articulates them as models fo theories. Concepts are defined, and statements about the rela- tionships among them are formulated, ‘These propositions are sup- ported by empirical and/or anecdotal evidence or defended by infer- ‘ences and logical reasoning. This type of knowledge is manifested in the works of nurse theorists who seck answers to questions such a8, Who is our client? What is i¢ that nurses do that influences persons" health (Meleis, 1985)? These theorists develop comprehensive for- rmulations of the nursing world, They use knowledge from other disciplines but through reflection and imagination evolve perspec: tives on that knowledge that are unique to nursing. They are influ- fenced by procedures followed in the development of other fields but adhere to procedures supportive of the values and purpose of nurs- ing. Conceptual knowledge is the product of reflection on nursing phe- nomena. Tt emanates from curiosity and evolves from innovation ‘and imagination in inquiry, along with persistence and commitment to the accumulation of facts and reliable generalizations. This type ‘of nursing knowledge requires logical reasoning and comes primar ily Trom individuals who take the position that knowledge is con: structed within a context, and its development is a never-ending process ‘Empirical knowing has influenced the development of conceptual knowledge in nursing through a dynamic interplay between system- atic observation (empiric) and theorizing (reflecting, describing, tynthesizing) (Weekes, 1986). The results of an inguirer’s own research and that of others are used to support the propositional ‘ructure of frameworks or theories. But imagination and risk taking are important in ther origination, Will aesthetic knowing lead to formal conceptualizations of nurs ing that reflect its ar? Will conceptual frameworks and models emerge from ethics as pattern of knowing to describe this dimen- tion of nursing? The answers to these questions depend on the degree to which nurse inguirers can view multiple ways of knowing ‘a equally valuable in contributing tothe mission of nursing. ‘The credibility of conceptual knowledge rests, in part, on the ‘extent to which nurses find ureful models and theories in communi ‘ating what they know. Whether or not a particular conceptual for ‘mulation holds up to critical appraisal depends also on its coher- fence and logical integrity—two criteria for evaluating theories (Meleis, 1985; Chinn & Jacobs, 1987), ‘Conceptual knowledge is often communicated in the form of propositional sentences. ‘Thus itis the propositions and their rela tionships to each other that are evaluated for credibility, Chisholm's six levels of epistemic preferability illustrate the criteria for evaluat: ing propositional credibility. Schultz (1987) explicated these levels with a proposition exemplifying a nursing knowledge claim: Nursing acts influence persons’ energy exchange for healing and Iealh, For the person wh believer this aon the statement fa (1) sc presenting to him or her at «particular point in time; (2) the claim hat ome presumption in its favor because tis not contradicted by other indie (2) the dain i judged vo be acceptable because it not discon frmed by the st of propositions having some presuoption in their favor: (4) the claim i epistemically in the dear because is noe incon firmed by the set of acceptable propositions and therefore (5) the claim is beyond reasonable doubt, Having met these conditions, the claim it Judged tobe (6) evident orceresin (p14). These are stringent criteria, Since nurses attend to individual expe- riences as well as to general patterns of experience, we may need to formulate differen criteria of eredibilty forthe conceptualization of nursing phenomena Empirical Knowledge ‘Empirical knowledge results from research. By research, we do ‘not mean simply the empiricist approach per se but also historical, phenomenological, interpretive and critical theory approaches 220 (Chinn, 1986). Empirical knowledge is manifest in published reports and is often used to justly actions and procedures in prac tice, It forms the basis for new studies and thereby contributes to the cumulative body of knowledge of a discipline. It often stimulates theoretical coneeptualizations. ‘Retearchers rely, in part, on received and procedural knowledge to inform their inquiries, but the hypotheses they test may originate in subjective knowledge; that is, their experiences with and reflec tions on nursing phenomena may give rise to hunches that lead t0 innovative methods or approaches to inquiry. If the empirical inquirer is also a practitioner, sel-knowledge and practical know! ‘edge may be brought to bear on the methods of inquiry. It is less ‘lear how the aesthetic or ethieal patterns of knowing contribute to the development of empirical knowledge except that unually (8) researchers adhere to ethical precepts in the conduct oftheir studies and (b) nurse inguirers are turning to the arts and humanities for approaches to systematic inquiry. ‘Advocates of different types of research approaches and methods have carved out criteria to validate their findings that are congruent with the particular designs and epistemological orientations that they follow (Gortner, 1984; Sandelowski, 1986). For all, however, the credibility of empirical knowledge rests on the degree to which the researcher has followed procedures accepted by the community of researchers and on the logieal derivation of conclusions from the fevidence without bias or prejudice (Schultz, 1987; Gortner & Schultz, 1987), Of particular importance is whether or not the researcher is cognizant of previous research findings, knowledgeable shout the procedures by which they were discovered, and dedicated to basing new research efforts on previous knowledge (Benoliel, 1987), In addition to the procedural criteria accompanying various research designs and methods, the credibility of empirical know! tilge is assessed by the systematic review and critique of research published in annual reviews (Werley & Fitzpatrick, 1983-1986; Fitepatrick & Taunton, 1987), by consensus conferences focused on corroborating what is known about specifie phenomena (e.g., pain) (National Institute of Health, 1987), and by invitational conferences {o clarify the state-of-the-art on a topic and suggest new directions (0 be taken (Duly & Pender, 1987). The epistemic preferabilty cr teria enumerated above for conceptual knowledge claims may also be useful for assessing the credibility of empirical knowledge claims. ‘Ukimately credibility erteria must be consistent with nurses’ var- ‘ous ways of knowing and types of knowledge. Can criteria be devel: ‘oped to accommodate the epistemological plurality of nursing, its complexity and holism? Is there one set of criteria or are there Sev- eral? These are unanswered questions, but let us consider the poss bility tha the criteria for accepting knowledge vary for each type of knowledge. Conclusion ‘Throughout this paper, we have deliberately avoided using the concept of “truth.”” Unfortunately inquirers from difering and con- tradictory perspectives have a propensity to put forth the view that their way of knowing yields she truth rather than a truth. Perhaps it is inappropriate to use the language of truth in nursing or in any practice discipline chat deals with complex human experiences. Per haps comprehending the context and patterns of human experi fences, adjusted for individual differences, is more appropriate for claiming universal validity (Polanyi, 1964; Visintainer, 1986). Per- hhaps it is not sufficient to speak of facts alone, rather we should ion and facts. Pethape it is not enough 10 research as the medium for knowledge development; concep: jon and expert knowledge from clinical practice may be equally powerful and credible Tf we agree that there are different ways of knowing, dillerent unknowns to be known, different propensities of knowers for know- ing and different aspects to be known about the same phenomenon, then perhaps we can develop appropriate eriteia for knowing from ‘what we do know and, then, for knowing what we want to know. 73. IMAGE: Journal of Nursing Scholarship Nanving Epnemology: Trains, nvighs, Questions —_ Reteencee Aelnby M. 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Annu Review of Nersng Reseach Wah 1, IMAGE ANNUAL INDEX Alerander, Mary A. and Blank, Jacqueline di, “Factors Reltied to Obey in Mover Ameran Preschool Chiren" Vol 20:2, p. 79-82, 1088. ‘Andersen, Joan E. and Briggs, Lyne L., “Nursing Diagnose: A Study of Quay ‘and Supportve Evidence" Val. 20:3. p” 141-144, 1988 ‘Ammon Gabercon, Kathleen B. and Piantanida, Maria, “Generating Ressks trom Qualtative Bal Vol 20:2, p. 159-161 1388, ‘Avant, Kay ., "Book Review Cose Sues Nursing Theory,” Vel 20:1. 56, "588 ‘Baggs, Judith C. and Schmit, Madeline H.,"Colaboraton Betwoen Nurses and ican," Vl. 20:39. 145.199, 1988, ‘Baranowsk, Madelon Vsintainer, “Book Review: The Primacy of Caring —Siress ‘nd Coping in Heath and Bincss "Vol 80°. p. 113-114, 1088 Brgoten, Dorothy, Brown, Linda P:, Munro, Barbara, York, Ruth, Cohen, ‘Susan M., Roncol, Marianne and Holimgeworth, Andrea. “Ear Dscorge and Spocnit Tansonal Care” al 20:2. 64-68, 1988, Camille Rosemary, "On Elegant Weng” Vol 20° p. 169-171, 1988 Cannon, Barbara, and Brow, Julia S.,“Norees Atitudes Tosurd Impaired ‘Coleaguer” Vol 30:2, p, 96-101, 1988 Ccason, Caroin L. Cason, Gerald J. and Redland, Alice R, “Peer Review of everch Abaracis “Vol 20:2. i210 1988, Chins, Peggy I, Book Revew: Nkne Chovee, Taking Chances: Nurse Lead ts Tel Ther Storie,” Vol 20:3 p. 178-174, 1588, Clinton, Jacqualine, “ejected Proposal: What Nex?” Vol. 20:1, p. $4, 1988 Constaitina, Rose E., “Comparcon of Two Group Interventions for the Bereaved" Vol 20:2 p, 85-89, 1988 Davi, Tey and Jensen, Louie, “Ideaslyng Depresion in Medial Patents,” Val 20-4.p. 191-195, i988, ‘el Bueno, Dorothy, "The Promise and the Realty of Cetin,” Vol 204 2-311, 1988 Donovan, Consianee 7, Book Review: The Profesional Commitment: ees nd Ecsin Nerang Vo 2011, p. 56-57. 1988, Drake, Mary Louie, Verhulst, Diana, Fawcett, Jacqueline and Barger, Diane ager, “Spouses Body image Changes During and Aer Pragnancy. A Repes ‘ton n Canada" Vat 20°29. 8895, 1988 Drew, Barbara J. "Devaluaton of Bologes! Knowledge,” Vol. 20°, p. 25-27, "se, Gaffney. Kathleen Flynn, “Prenatal Maternal Attachment,” Vol 103-209, 1988 GGttaroth, Sister Lucia, "Long-Term Care Resource Requirements Before and ‘Alte theProspecve Payment System, Vel 20 iep. 7-11, 988, Germain, Cara P. and Nemchik, Ria M.,"Dibeien Sell Management and Ho pialeaon" Vol 20:29. 78-75, 1988 Gartner, Susan Rand Schult, Phyl Methods Val 20:1, 22-24, 1988, Hamilton, Diane, "Faih and inence,” Vo. 203, p. 126-127, 1988 Hezekiah, Jocelyn, “Colonal Hersage ond Nursing Lendership in Tnided and “Tatas,” Val 203, p. 198-158, 1088 ‘Ons of Nusng Kaswledge" Vol. 20:4 p, 223, 1988, id Morrison, Eileen F. The Progresion of Knowledge 9 Nurs Ing: A'Seorch for Meaning Wol 208 p 282-22, 1988 "Approaches fo Nursing Scence ‘Volume 20, Number 4, Winter 1988 Volume 20, 1988 Lund, Ulla, Sader, Marten and Waerners, Karl, “Nursing Theoses: A Creal Mtl 20. pS, 1388 = i, {Uymaugh, Joan E.'and Fagin, Clave M., “Nursing Comet of Age.” Val. 20; 184° 190, 1988) Méfirie, Angela Barron, “Mental Heal Elects of Women's Mutiple Roles.” Vol 2-1 p 41-7 1068, “McCloskey; Jonnne Coml and McCain, Bruce, "Varbes Related to Nurse Per formance" Vol. 2034, p. 203.207, 1988 Medait-Cooper, Barbara, “The Elects of Handing cn Preterm Infants with Bron hopulmonary Dysplea" Vol.20°3, p. 132-134, 1988 Mercer, Ramona T., "Book Review: Gay ond Lesbion Parents,” Vo. 20: D, 234.235, 1988 Mist, Merle H., "Uncertainty nies,” Vol. 20:4, p, 225-292, 1988, Norris, Anne IE, “Comnive Analy of Contactptive Behavior,” Vol. 20:3, 135-140, 1588, Oshansy, Elen Frances, “Rezpones to High Technology Inertity Treatment, Vol 2035, p. 128-181, 1988, Podeadky, Debra L. asd Serion, Dorothy 1, Paton” Vol 20:1, 16-21, 1988, Presale, Jana Land Fitpatrick, Joyce J, "Contabutons of Rosemary Eis to ‘Rrowledge Development for uring Val 20:1, p. 28-90, 1388 Redeker, Naney Schmieder, "Hess Baits and’ Adherence in Chron ness” Val. 26-1,p. 31-35, 1588 Rew, Lyn, “ftuon ip Decson Making "Vol 20:3, p. 190-154, 1988 Richard, dudith A, “Congruence Betwcan Ineehit Reports and Patents! Acta ‘Condicnn" Val 20-1, p. 4-6, 1988, Schmelzer, Marilee and. Anema, Marion G., “Should Nuses Ever Lie to Paton?" Val 20:2,p. 110-112, 1988 Schulte, Phylis Rand’ Mele, Alt 1, “Nursing Epistemology Tisghis, Questions," Wal 20:8, p, 217-231, 1988 ‘Smith, Shela Kx "An Anais the Bherismenon of Deterioration i the Cit “al Val. 26-1, p. 12-15, 1988 Steinke, Elaine F.'Oker Adula Knowledge and Artudes about Senusiy and “agin” Vol 20:3, . 93-9, 1988, nt, Patricia E. and Hall Joanne M., "Sigma, Heath Belels and Exper ‘shee wth Heath Caren Leshan Women,” Vol 30:2 p 69.72, 1988, Thompson, Joh D., ack Review [Hae Done My Duy Flaence Mghingole Ime Crimean We 1854-1880," Vol. 20:3,» 172, 1988 Warner, Sandra L. Rose, M. Candice and Clark, Lr, An Analy of Entry Info Proce Argument: * Vol 20:4 . 212-216, 196, Wiiamson, Kenny Mallow, Selleck, Cynthia S., Turner, John G., Brown, Kathleen C, Newman, Karen Davideon and Sis, Ann Travis, Occup anal Health Hazrds lor Nurser: nection * Vol, 20:1. 4-53, 1688, Wiltameon, Kenny Mallow, Turner, Joan G.,.Brown, Kathleen Cov Newman, Karen Davidion, Sires, Ann Travia and Selec Cynthia SCs) Health Hazards fo Nuts Part > Val 20-3, p. 162108, 1988, ‘Young, Jane Coolidge, “Ratonsle for Cinican Sei Dscosure and Research “Agenda,” Vol 20-4.p" 196-199, 1988, ‘ake, Lina Kardahi, Khoury, Mey and Nugent, Kevin, “Neonatal Behavior of PrensalySrestd Lebanese Infant" Vol 20'4 p, 200-202, 1988, ‘Nurses! Reactions to Dil rations, 221