The holistic caring process is experienced within reflective practice. Insights derived from the four patterns of knowing identified by Carper guide the nurse’s process within the nurse-person interaction.⁹ Empirical or scientific knowledge is based on objective information measurable by the senses and by scientific instrumentation. Ethical knowledge flows from the “basic underlying concept of the unity and integral wholeness of all people and of all nature.”¹⁰ Aesthetic knowledge draws on a sense of form and structure and of beauty and creativity for discerning pattern and change. Personal knowledge incorporates the nurse’s self-awareness and knowledge (emotional intelligence), as well as the intuitive perception of meanings based on personal experiences, and is demonstrated by the therapeutic use of self.

The Johns model of reflective practice within Carper’s fundamental ways of knowing in nursing enables “the practitioner to access, understand, and learn through her or his lived experiences and, as a consequence, to take congruent action towards developing increasing effectiveness within the context of what is understood as desirable practice.”¹¹ Within this structured reflection a set of cue questions challenges the nurse’s unexamined norms and habitual practices, allows for interpreting the nurse’s subjective experience, and facilitates projection of the effects of nursing actions on the observed outcomes (see Exhibit 7-1).

The holistic caring process involves collection and evaluation of data not only from a rational, analytic, and verbal (or left brain) mode, but also from an intuitive, nonverbal (right brain) mode. Intuitive perception allows one to know something immediately without consciously using reason. Clinical intuition has been described as a “process by which we know something about a client that cannot be verbalized or is verbalized poorly or for which the source of the knowledge cannot be determined.”¹² It is a “gut feeling” that something is wrong or that we should do something, even if there is no real evidence to support that feeling. Within the caring relationship between nurse and person, intuitive events emerge as the nurse is open and receptive to the person’s subtle cues.

Effken describes this perception as the direct detection of environmental information.¹³,¹⁴ Intuition, characterized as direct perception, occurs when the holistic nurse perceives in the environment higher-order variables that call for action. Framing intuition as direct perception offers an explanation for how experts who perceive complex higher-order variables cannot report with accuracy underlying lower-order properties, as well as how new information, outside of the nurse’s previous experience, may be interpreted intuitively as an opportunity for action. Expert nurses, like “smart devices,” sensitive to and capable of acting immediately upon higher-order information, directly apprehend environmental information as a whole—as a complex or composite variable. When characterized as direct perception, intuition becomes an “observable, lawful phenomenon that is measurable, potentially teachable, and appropriately part of nursing science.”^13p252 Where Effken’s definition could limit intuition to the objective, rational, cognitive realm of the expert nurse, the concept of emotional intelligence suggests that emotional intelligence facilitates interpretation of the nurse’s perceptions.

Emotional intelligence informs the gut feeling dimension of intuition.¹⁵ Described as an ability,¹⁶ a set of traits and abilities,¹⁷ or a combination of skills and personal competencies,¹⁸,¹⁹ emotional intelligence is the assessment, expression, control, and use of emotions within the nursing intervention.²⁰ Emotional intelligence directs the emotional labor of the caring relationship associated with the holistic caring process. Emotional labor “is a process whereby nurses adopt a ‘work persona’ to express their autonomous, surface or deep emotions during patient encounters.”^21p203

Established on Goleman’s²² theoretical framework, Robertson¹⁵ identifies four building blocks for cultivating emotional intelligence within the healthcare setting. Internal domains (intrapersonal) include Self-Awareness and Self-Management. Social Awareness and Relationship Management comprise external domains (interpersonal). Self-Awareness, the ability to recognize one’s emotional response pattern to specific people and situations, is demonstrated through recognizing one’s own emotions and their communication (facial expression, body language, word choice, and voice tone) to create congruence between intention and message sent. Self-Management, the ability to modulate one’s emotional response, draws from emotional awareness to manage how those emotions are expressed. This response may be expressed through surface acting, in which the nurse changes the outward expression to display feelings appropriate to the situation, or through deep acting, in which the nurse changes the deeper feelings to those appropriate to the situation.²⁰ The purpose is to create safety for focusing on clientcentered feelings and concerns. Social Awareness demonstrates the ability to accurately perceive and understand another’s emotions even if they are expressed through a different cultural lens. Relationship Management consciously accesses Self-Awareness, Self-Management, and Social Awareness to support relationship enhancement and to avoid relationship-ending confrontations.