Ways of Knowing in a Clinical Case

Karen Fugate

University of Central Florida

WAYS OF KNOWING IN A CLINICAL CASE 3

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 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.

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 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.

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 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.

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.