N 7X PRI Cy ‘Unknowing’: Toward Another Pattern of Knowing in Nursing Patricia L. Munhall, an, Edo, Psya, FAAN There is an important rationale for nurses to learn how to “unknow’’—to be authentically present for the patient. AsIsiton this hatd bench Isuddenly yearn for one last long look, and not ‘only ofthe phenomenon of litte joe and little Michael, but ofthe others too: Ellen, four, and Annie, seven months, sharing a peach... AS I watch, them now as adults the fact that I will never see their toddler selves again is tormenting [ane Smiley,| Ordinary Loveand Good Will, 1989 When you are thirty, the child is two. At forty, you realize that the child inthe house, the child you live with, is stil, when you close your eyes, or the moment he has walked from the room, two years old. When you ate sixty and the ebild is gone, the child will also be ewo, bur then. you will be more certain, Wersheets, wet kisses. A flood of tars. AS you remember him the child is always wo. Ann Beattie? Piewring Will, 1989) I “ye foregoing literary excerpts illustrate the power of individ ual perceptions and the different struc- Presented at the annual caring confer. ‘ence sponsored by lota Xi and the Col lege of Nursing, Florida Atlantic Univer sity, Florida ‘Nuts Ouoox 1993;41:125-8, ‘Copyright © 1983 by Mosty-Yew Book, I 15s 0009 5854/9376100 1 10" 35/1/4460 NURSING OUTLOOK MAY/JUNE 1993, tures of subjectivity that call for a fifth pattern of knowing in nursing to be ac knowledged, that of “unknowing.” Many nurses have endorsed in our nursing literature, and in some curric- ula, a structural, categorical approach to knowledge, reflected in Carper's Fundamental Patterns of Knowing in Nursing. These four patternsof know- ing are part of Faweetts' proposed “metaparadigm’ for nursing.* This article focuses on the state of ‘mind of unknowing as a condition of ‘openness. Knowing,” incontrast leads toa form of confidence that has inher- entin ita state of closure. The “art” of unknowing is discussed as a decenter” ing process from one’s own organizing principles f the world Unknowingis not simple, but it isessential to the unr derstanding of subjectivity and per spectivity, These concepts are di cussed, and a suggestion is offered that for understanding to emerge the per cceptual field that evolves when two or ‘mote personal universes come together ‘ust be clearly focused upon by the involved individuals. Italsois proposed that in this perceptual field of two or more subjective perspectives, called the “intersubjective space,” all sources of human understanding, empathy ~and also conflictcan and will evolve. THE ART OF UNKNOWING Unknowing, paradoxically, is another pattern of knowing, Knowing that one does not know something, that one does not understand someone who stands before them and that perhaps this process does not fit into some pre existing paradigm or theory is critical to the evolution and development of knowledge To engage in an authentic encoun: ter, one must stand in one's own 50° cially constructed world and unearth the other's world by admitting, "don’t know you. {do not know your subjee tive world.” When a nurse stands with another human being, forming impressions, making a diagnosis, formulating a per ception, and knowing whatis best, that nurse may indeed practice an efficient type of nursing based on the empirical, ethical, personal, and esthetic patterns of knowing, Still, knowing of this kind leads toa form of confidence that has inherent in ita state of closure, To be authentically present to a patient is to situate know: ingly in one’s own life and interact with full unknowingness about the other’ life. In this way unknowing equals openness (Figure 1). This is by no means easy. Unknow: ing a5 an artis not presently acknowl: edged and calls for a great amount of introspection, However unknowing e tnains essential to the understanding of intersubjectivity and perspectivity. In other words, itis essential that we un derstand our self and our patient to be two distinctive beings, one of whom we do not know. Munhall 125 1Plucing aside a cogent argument that Individual Openness might speak co inst how well nurses hee kkaow themselves, there can be little 1 dont know you doubt that they do not know the pa 3 t : tient. Each patient has a unique per- theoretical stance "bias spective of their situated context and a ~ ee cancion oie aes Go the extent possible) preudice held petson in the world, This is their per preconceptions in i spectvity, theie worldview, thei reat : ity. When urses and patients meet, stereorypes abeyance two perspectives ofa situation need to ae be recognized. Thus the process of ir 7 rersubjectivity begins to create the per ceptual field (Figure 2) | Figure 1. The art of unknowing, INTERSUBJECTIVITY tually interpreted, The mutuality here These ideas of unknowing and de- Intersubjectivity is not a difficult con reflects the nurse and patient commu centering ate very practical realities to cept tounderstand, though many writ- nicating, reflecting, and validating the nursing practice and esearch. Without ingsabout itseem intent at making the meaning of the patient’s experience. extensive examination and introspe concept complex. What ischallenging The unknowing stance of the nurse is tion of and about the substance of the is practicing in a wideawake manner. primarily motivated by the intent to intersubiective space, two dangers Tntersubjectivity is the verbal and come to know the patient's world, The might occur that ate counterproducy nonverbal interplay between the orga’ patient "knows" the nurse as one who tive to understanding and to patients’ tized subjective world of one person is engaging in the process of coming to health, growth, and becoming. Nurses and the organized subjective world of know so that the nurse can better un must understand that their perceptions another? Itis one person's subjectiv- derstand, empathize, and care in an of the world and of health may or may ity interseeting with another's subjec- authentically individualized manner, not assist the patient, Stemming from tivity. Incach person’ssubiective world the nurses’ subjectivity, if not eclipsed is organization of feeling, thoughts, A DE-CENTERING PROCESS temporarily by the patients’, are two ideas, principles, theories, illusions, This art of unknowing when two sub dangers of knowing. They are inter distortions, and whatever else helps ot jective worlds intersect is discussed as subjective conjunction and intersuby hinders 2 person. Individuals do not ade-centering process, one that deen’ jective disjunction.* know about another's subjective world ters us from our own organizing prin | unless they are told about it, and even ciples of the world.’ This unknowing Personal Universes - | then one cannot be sure, Figures 2 and art enables empathy of the situated Subjective Views of Reality 3 illustrate visually the concept of in+ context where nurses understand the tersubjectivity actual essence of meaning the patients In Figure 3 the illustration depicts experiences hold for them. where many nurse theorists say nurs: Figure 3 might be what Sartre!? ingtakesplace. Sometimes thisiscalled thought of as utmost importance in the “‘in-between,"* but visually it de- understanding and evaluating his com Intersubjectivity - picts a connection that for the purpose ception of the human situation, Thisis a of this article is called a “shared per- called “being for others.” Sartre feared ceptual field.” When this shared per: in this the loss of self, but what is por: Person] ceptual feld is pulted out by the nurse, ayed here as de-centering isa tempor 1 it becomes a whole, 3s shown in Fig? rary suspending of self as the nurse a: ure 4. lows the patient's subjective structure [A Shared Percepwual Field Ieis in this field that caring, under- of reality wo become known, The nurse | gyhere subjectivties interact standing, empathy, conflict, and mis" is metaphorically eclipsed by a patient understandings take place. This, then, in order to”know’ che patient. Nurses is no small matter. For cating to be re- encourage patients to reveal their per” leas alized, this perceptual field that spectives without interuption or the emerges, this inelligible whole or in- inttoduetion of alternative interpret | | Some a ive space, must be clearly fo: tions. Nurses allow patients to be seen | Figure 2. Personatuniverses. neces Staion ual sndyeed inde and etd iscsi conda redpneruus #2 426 Munball VOLUME 41 +NUMBER 3. NURSING OUTLOOKFigure 3. The nursepatient shared perceptual field INTERSUBJECTIVE CONJUNCTION In the instance of intersubjective con- junction nurses are alerted to this cit~ ccumstance by feelings of comfort with the patient. Nurses need to understand that this comfort is originating from their own perceptions of knowing, We have yet to explore the meaning of this comfort for the patient. Although this initial compatability may feel good, it could cause problems unless an atti- ude of questioning and unknowing precedes the continuation of the per ceived shared subjective stance. In intersubjective conjunction it seems the two subjective interpreta tions of the world match. The patient is an analogue model of the nutse, oF vice versa, Thoughts such as “We think alike" “We feel alike” “We see things the same way” “We agree on Perceptual Field Figure 4. Perceptual field what's to be done" and “We have good rapport” should alert the nurse to this situation. ‘What is occurring is that both per- sons share closely similar perceptions of the experience. However, before gor ing further, it is suggested here that the nurse proceed with an air of mystery and an attitude open to alternative in terpretations. Difficulties inherent in intersubjective conjunctions Closure is the main difficulty inherent in intersubjective conjunetions. While two persons (inthis instance a patient and a nurse) may share common atti- tudes, the reasons and the histories may be very different. So shared 35° sumptions of reality, or conjunction, ay Imersubjeciviy Intersabjecivty Pasent Eclipses Nurse ® + Ineligible whole De-Centering Nurses line opens ‘Coming to Know the Patient Knowing the Other Figure 5. Knowing the other. MUIRSING OUTLOOK MAY/IUNE 1993 + Close further exploration + Achieve the status of obiective re ality (when ie may not be $0) + Representa shared defensive solu tion «+ Represent a shared illusion or de- lusion + Close off testing other alternatives «Eliminate exploring origin of per cxption An example of this could be a nusse and a patient sharing negative feelings about various things~people, places, or an experience. Their agreement be comes an agreed on truthful objective reality. In actuality, these shared per ceptions could bea way that both these individuals pecject inner difficulties conto the outside world. The danger, of course, is that the inner difficulties go left unexplored and the conjunction becomes collusion. Iti critical fn this intersubjective space to go beyond ot underneath the agreed on perceptions of the experience The art of unknowing in intersubjective conjunction Unknowing can be the impetus 10 finding out. Where there is agreement about the world, nurses should de-cen: ter, hold theis beliefs in abeyance, and allow others totell their stories, Nurses allow others to enlarge their construc: tion of their social reality. Before, nurses said, “T know how you're feel ing,” which is doubrful, The knowing part comes from allowing the other to be known from individual perceptions, not those of the nurse. So agreement in the intersubjective space does not mean ‘mutual knowing. Unknowing is een tial o "knowing," just asin intersubiec” tive disuntion, INTERSUBJECTIVE DISJUNCTION In the instance of intersubjective dis: junction there is disparity and disagree ment with the subjective perceptions of the two socialy constructed realities of individuals. [tis in this disjunction that misunderstanding and conilict may be counterproductive and non therapeutic for patients, ndisiunenion, Munhall 127nurses believe that their interpretation of a situation isthe better one and that the patient’s interpretation would be improved if it were altered. Rather than assuming an unknowing posture regarding the patient's perception, the nurse attempts to change the subjective meaning for the patient. In contrast, then, to conjunction, in which there is agreement about the world (which may be obstructional 2s well), in disjunction there is disagreement, and this too may be extremely counterpro" ductive to understanding and empathy. Difficulties inherent in intersubjective disjunction ‘The danger in disiunetion or disagree ‘ment is mainly one ofthe projection of a nurse's perception on a patient. Once again, there is closure to the meaning and desires of an individual person— the patient. Disagreed upon assump- tions of reality, or disjunction, may: * Close further exploration + Become self-fulfilling + Alter the patients perception of reality + Give the patient the impression that he is wrong + Interfere with patient's defense ‘mechanisms ‘An example ofthis could be “know: ing what is best forthe patient. A case that comes to mind is a nurse who dis ‘couraged a patient from marrying a man who was obviously a poor choice for this patient. The patient did not ‘marry; instead she had a series of psy~ cchotic episodes. Would they have hap- pened anyway! We do not know. But de-centering here to find out what was going on with this patient from her perspective was essential Instead of di agnosing and prescribing, the nurse needed to unknow, listen, and under stand the meaning ofthis patient's per- ceptions The art of unknowing in intersubjective disjunction Where there is disjunction, there is the potential for misunderstanding the meaning an experience has for a pa- tient. If the nurse "knows" what is best and attempts to communicate this to 128° Munhalt 1 the patient, the patient may fee! mis: SUMMARY : understood, coniicted, and may be- Knowing is wonceerul, but itis just a come resistant to the “knower.” After guiding means. U=xnowing isa condi- all, the patient is a “knower" as well. tion of openness. This unknowing in ‘Again, nurses must hold their own the intersubjective space of two people beliefs and assumptions aside. For in- or people of two culnures allows others stance, if nurse believes the situation to he. This art of unknowing may en- ta be hopeless and 2 patient is hopeful able a nurse to uncerstand, with empa- despite all evidence, to be empathic thy, the actual essence of the meaning. and tohelp the patient feel understood, an experience has for # patient, This the nurse tooshould attempt hopeful pattern of unknowing focused herein attitude. Many nurses can speak to a on the intersubjective whole between patient they had every cause tobelieve patient and nurse is applicable 3é well to be hopeless as far as improving or to learning in a more formal sense. To becoming more differentially inte- be open to learning one needs to pos: grated only to find that their “know- ture oneself in a postion of unknowing ing” was based on usual cases in simi- to hear colleague a teacher, astudent lar circumstances. The danger here is To provide and find openness isto be obvious, in that the self-fulfilling able to say, “I never thought about it prophecy may be operating and the par that way,”” and at once experience tient may begin to perceive hiscireum the wonderment of coming upon an stance as the nurse does. "unknown." THE FIFTH PATTERN OF KNOWING: UNKNOWING “"Knowledge screens the sound the Salley Ordinary lve and good wll. New York Random Howse 198910. third ea hears, so we ear nly what ee na we know. dora House, 1989.38, Our listening characteristics are of+ 3. Caer 8 Fundamentals pater of kaow- ten those of dignosing and preseib- int Ads Nu Si Bot1303 i ne ethan, 4 Faweet |, The acuperdign of nang: The diagnosing and prescribing" greene sunsand rare renenens Ite comes from our knowledge and our yiaayatr subjective perceptions. This may lead 5. Atwood D, Siolorow R. Structures of subiee: to premature closure to other possibil- Sve. New ney Lawrence Elous Aas lates, 19844753 ities, interpretations, and perceptions, pat TSS ae REFERENCES: ‘The fact that this occurs isa result of "New York: Nasional League for Nunang, someone else's knowing. Someone else 1990! teaching us to know, to put together, co” Wt |. Nursing. human sence and i> man are, Norwalk, Connecticut. Appleton eae eee Cencury Cros, 1985 “The compulsion to make sense is2 4, Mais, Theory development and eursing resistance to unknowing.”"' The pat practice a syopssol «study ofthe theo tem of unknowing can lead toa much deeper knowledge of another being, of Etat age for Nuning. 1988 different meanings, and interpretations 9, genner P, Wrubel J. The primacy of caring, of all our various perceptions of expe: sues and coping in bedi ad lst rience. The intent of bracketing in oe Park, California, Addison-Wesley, qualitative research isone in which the 45. 7p seing and nothingness New Yee researcher assumes the posture of the '” wanes erst baive listener. ores Teste unknowing New ese ey aa Armin, fc, 198967 12, Hse IH Scene and meicne Bou ee de Cou Shimbhal 9822 chil, and be prepared ive wp vey preconcsived exon, flow ing humbly wherever and'o what. PATRICIA L, MUNHALL isa professor at ver ays nature lead, oc you shall Florida Atlante University, Boca Raton, team noching Florida, VOLUME 41 «NUMBER 3 NURSING OUTLOOK practice diabetic In, Mocca Ped. New ap proaches cotheory development New Yorks