Empirics is defined as the science of nursing, “based on the assumption that what is known is accessible

through the senses: seeing, touching, and hearing.”7 White4 observed that the empiric pattern rests on the
notion of an objective, knowable reality, about which scientists may objectively draw conclusions and
gener-ate testable hypotheses. This pattern has obvious impli-cations for the technically sophisticated
practice envi-ronment of modern nursing.
It is easy to identify the empirical data collected from Nightingale’s practice. A majority of her text is devoted to
the knowledge obtained through the 5 senses and based on detailed observations. Nightingale valued the
significant information acquired by virtue of her sight, hearing, touch, and smell. Her evidence consisted of
epidemiologic data, meticulously recorded and main- tained during her years of practice. Nightingale used
these sensory observations to know that washing was a significant and therapeutic nursing intervention for
clients. She additionally deduced that the psychological and physiological responses and benefits were
measur-
able, verifiable, and useful for improving clinical out-comes.3,7,22 For example, in her chapter “Personal
Cleanliness,” Nightingale18 offered the following ob-servation on steaming and rubbing the skin:
Every nurse ought to be careful to wash her hands very frequently during the day. . . . you can really
keep yourself cleaner with a tumbler of hot water and a rough towel and rubbing, than with a whole
apparatus of bath and soap and sponge, without rubbing. . . . [Washing] has quite other effects than
those of mere cleanliness. The skin absorbs the water and becomes soft and more perspirable. To
wash with soap and water is, therefore, desir-able from other points of view than that of cleanliness.
Many more examples of empirical knowing abound within Nightingale’s text. Congruent with the
critical question for the empirical pattern of knowing, “What is it and how does it work?”,7 Nightingale
established a foundation of facts and actions that remain critical to current nursing practice. An example of
this emerged when she returned from Crimea determined to establish a government investigation and
remodeling of the army medical system. While at Scutari she wrote Notes on Matters Affecting the Health,
Efficiency and Hospital Administration of the British Army, “almost a thousand pages long, and bolstered
with tables and flurries of statistics.”20 At the time she was quoted as declaring, “I stand at the altar of
murdered men and while I live I shall fight their cause.”
However, Nightingale18 cautioned:
In dwelling upon the vital importance of “sound observation,” it must never be lost sight of what
observation is for. It is not for the sake of piling up miscellaneous information of curious facts, but for the
sake of saving life and increasing health and comfort. The caution may seem useless, but it is surprising
how many . . . practically behave as if the scientific end were the only one view.
This statement again reflects that Nightingale, at some level, relied on much more than statistical,
empirical scientific knowledge. She implied, in addition to the empirics and science of nursing, the
existence of additional ways of knowing and kinds of knowledge to guide research, practice, and social
change.

Aesthetics
The aesthetic way of knowing is experiential, often non-verbal, and shared by the nurse and the client. Each
moment is unique and a learning encounter unto itself. Based on that shared moment and perception of what is
meaningful, the course of nursing action unfolds as a “transformative art/act,”7 one honoring “the art of
nursing lived fully in relationship”23 and caring.24 Aesthetic knowing invites the imagination and creativ-
ity of the nurse-client encounter to envision infinite possibility. Aesthetic knowledge “is expressed through
the actions, bearing, conduct, attitudes, narrative, and interactions of the nurse in relation to others.”7 Con-
gruent with this description, Carper25 asserts that em-pathy is a basic tenet of aesthetic knowing:
Empathy—that is, the capacity for participating in or vicariously experiencing another’s feelings—is
an important mode in the aesthetic pattern of knowing. One gains knowledge of another per-son’s
singular, particular, felt experience through empathetic acquaintance.
The critical questions for validating the aesthetic way of knowing are “What does this mean?” and
“How is this significant?”7 This type of knowing is not expressed through words or statistics; rather, it is a
non-discursive experience, a moment of synchronous reality.26 Drawings, paintings, poems, stories, drama,
movement, and music are examples of the expression of aesthetic knowledge.
In comments from her observations on rural hy-giene,27 Nightingale expressed a view that is represen-
tative of the aesthetic way of knowing in nursing. She challenged the nursing profession to examine the
im-portance of “how” nurses know about their patients, beyond the science and statistics and,
subsequently, how they use that knowing in decision making:
In these days of investigation and statistics, where results are described with microscopic exactness and
tabulated with mathematical accuracy, we seem to think figures will do instead of facts, and calculation
instead of action. . . . We wait to see whether the filth will really trickle into the well, and whether the foul
water really will poison the family, and how many will die of it. And then, when enough have died, we
think it time to spend some money and some trouble to stop the murders going further, and we enter the
results of our “masterly inactivity” neatly in tables; but we do not analyse and tabulate the saddened lives
of those who remain, and the desolate homes in our “sanitary” districts.
Nightingale clearly discussed the necessary presence of the nurse with the client, as well as interpersonal
interface and communication, as a pathway to knowing. She validated that knowing about the client is experi-
ential, as well as shared. In essence, for a nurse to be empathetic toward a client, she or he must be fully present,
at that moment, sharing the experience and what it means to both the nurse and the client at the time. Aesthetic
knowing is clearly bound by conscious-ness, proximity, and human interchange at various

levels. Nightingale promoted interaction and contact between nurse and client, basing nursing practice on
relationships and experiences. Nightingale28 appeared to be musing on aesthetic aspects of care when she said,
They [nurses] vary their own objects, their own employments many times a day; and while nurs-ing
some bed-ridden sufferer, they let him lie there staring at a dead wall, without any change of object
to enable him to vary his thoughts; and it never even occurs to them, at least to move his bed so that
he can look out of the window. No, the bed is to be always left in the darkest, dullest, remotest part of
the room . . . the craving for variety in the starving eye is just as desperate as that for food in the
starving stomach. . . .
This credo for successful nursing continues to be foundational in the new millennium, even when seem-
ingly overshadowed by shorter lengths of hospitaliza-tions, increased client-to-nurse ratios, and the need to
provide comprehensive care during the briefest possible interval of time.

Ethics
Ethics in nursing is described as determining whether the moment-to-moment nursing decisions are
morally responsible and deliberately positive.3 Ethics generically deal with doing more benefit than harm
in the actions that are taken during the care of clients. “The nurse is expected to meet the patient’s health
care needs with concerns for the client’s safety and best interests. . . . Society recognizes the profession’s
au-thority and expects members of the profession to act responsibly. Self-regulation is a characteristic of
an accountable, therefore mature, profession.”29 Nurses are accountable for their actions and have a
responsi-bility to honor the client’s expectation of trust, safety, and well-being. The ethical pattern of
knowing in nursing asks the critical questions: “Is this right? Is this responsible?”7
Ethical decision-making in nursing occurs often and within increasingly difficult contexts of care.
Conceiv-ably, many nurses may not even realize that they are making ethical decisions throughout an
entire day or shift. Many of these decisions present as common sense, yet the treatment choices are based
on moral judgments and perceptions. Situational and relational factors may complicate ethical decision-
making.4 Ac-cording to Bandman and Bandman29:
The nurse carries out the role of securing the patient’s interests, sometimes as the eyes and ears, arms and
legs of the patient. The nurse sometimes even single-handedly embodies the role of care-taker, protector,
and advocate, especially since there are occasions when no one else is in a position to fight as hard to help
the patient to win the . . . battle
Dunphy30 maintained that Nightingale framed all ideas through a moral compass, even as she encoun-
tered questionable practices by nurses in her charge. Realizing that the actions were not therapeutic or just,
she chose to educate nurses through her notes on nursing in an obvious attempt to heighten their ethical
awareness and positively influence their practice. She described the importance of ethical practice by
nurses:
I have known several of our real old-fashioned hospital “sisters,” who could, as accurately as a measuring
glass, measure out all their patients’ wine and medicine by the eye, and never be wrong. I do not
recommend this, one must be very sure of one’s self to do it. I only mention it, because if a nurse can by
practice measure med-icine by the eye, surely she is no nurse who cannot measure by the eye about how
much food her patient has taken. . . . Yet a nurse will often have patients loathing all food and incapable of
 any will to get well, who just tumble over the contents of the plate or dip the spoon in the cup to deceive
the nurse, and she will take it away without ever seeing that there is just the same quantity of food as when
she brought it, and she will tell the doctor, too, that the patient has eaten all his diets as usual. . . . Now
what kind of nurse is this?28
Nightingale’s commitment to ethical client care and well-being is evident throughout her writings. The
foundation for care is client-focused and directed to-ward optimizing client outcomes. Nightingale
depicted this process by advocating truthfulness, accuracy, and collaboration.

Personal knowing
Personal knowing involves a measure of self-knowledge, confidence, self-responsibility, and engagement with
life.7 It is expressed as a state of being, a personal experience reflecting inner and outer harmony, “know-ing that and
knowing how.”22 According to Carper25:
Personal knowledge is concerned with the know-ing, encountering and actualizing of the concrete,
individual self. One does not know about the self; one strives to simply know the self. The relation is
one of reciprocity, a state of being that cannot be described or even experienced—it can only be
actualized.”
Chinn and Kramer7 presented the critical questions for validating personal knowing in nursing as “Do I
know what I do? Do I do what I know?” This is accomplished through personal reflection, autobio-
graphical stories, thoughtful response, and the therapeu-tic use of self.
Reflection requires the integration of a wide range of information and understanding derived from all forms
of knowing and from other knowers, along with an internal accounting of how fully that which is known is
actualized or realized within the self of the knower. In the words of Lincoln,9 “Reflexivity [reflection] is
the ability to enter an altered state of consciousness . . . for the purpose of understanding with great
discrimination subtle differences in the personal and psychological states of others.” Responses from
others mirror or reflect back the ways in which the person is perceived. As the responses of others are
received, the individual gains insights that can be used in the self-reflection process, and the self becomes,
or is realized, as an authentic being in the world.7 “The nurse identifies herself as the human equal of the
patient, as a person with fellow feelings.”29
Nightingale devoted the majority of her life to identifying with a class of people apart from her own. 15
History has told the familiar tale of the London socialite who, after a calling from God, rebelled against the rules
of femininity and status and committed her life to healing the sick. There are numerous reflections of
perceptions (or mirroring) of Nightingale and her nurs-ing. The most well-known example is that “Nightin-
gale’s work made her popular with the men. They called her ‘The Lady with the Lamp’ in recognition of her
Turkish candle lantern, which she carried through the corridors packed with wounded soldiers.” 30 She has been
portrayed as making rounds by lamplight, deep into the night, wishing each of her clients a good night before
retiring from duty. In this light (both figurative and literal), Nightingale fit the description of personal knowing
in nursing as described by Carper25: “The nurse in the therapeutic use of self rejects approaching the client as an
object and strives instead to actualize an authentic personal relationship between two persons.”
Nightingale relied on reflection and response from her nurses, the clients, and even the physicians. She
stated: “A [doctor] who really cares for his patients, will soon learn to ask for and appreciate the information of
a nurse, who is at once a careful observer and clear reporter.” 28 Throughout her writings, Nightingale sup-ported
the idea of personal knowing and interpersonal relationships. As Fitzpatrick 31 noted, “Within this par-adigm, the
proposed relationship is that people derive meaning from life’s experiences and the extent to which life has
meaning influences the person’s health status.” In upholding the notion of interpersonal knowledge and
presence, Nightingale stated, “Apprehension, uncer-tainty, waiting, expectation, fear of surprise do a patient
more harm than exertion. Remember he is face to face with his enemy all the time. . . .”