Reflective practice in hyper acute stroke nursing: integrating patterns of knowing and trauma theory

Introduction

Stroke is a sudden and traumatic event that can leave individuals with life-changing physical, psychological and cognitive deficits (Stroke Association, 2013). Drawing on practice within a stroke unit, I understand that stroke care involves not only responding to patients’ complex medical needs but also supporting patients and their families as they overcome sudden physical boundaries, changes in identity, and uncertainty. In this environment, it becomes essential to understand how knowledge and theory inform practice and shape how nurses deliver care.

Knowledge is the foundational basis for effective, expert nursing practice (Chinn et al., 2022), and understanding the interplay among the different types of knowing is important. Epistemology, the Greek word for the study of knowledge, is essential for the development of nursing as a discipline and for building a reliable knowledge base (Johnson and Webber, 2010). Chinn and Kramer’s five patterns of knowing expand on Carper’s seminal four ‘ways of knowing’ to include emancipatory knowing, which highlights the importance of recognising social injustices and inequality within healthcare (Chinn et al., 2022). Carper’s four patterns of knowing, with the addition of Chinn and Kramer’s fifth pattern, provide a valuable basis for exploring how nurses integrate evidence, ethics and holistic care within their practice. However, knowledge alone does not shape practice; rather it is through reflective engagement with knowledge that it becomes clinically meaningful. Within the hyper acute stroke unit, reflection is not solely retrospective, but occurs in-action.

Alongside this epistemological lens, this paper will consider Judith Herman’s three stages of trauma theory. Although originating within psychology, Herman’s theory can offer an insight into the traumatic recovery process following a stroke. The aim of this paper is to explore how nursing theory and knowledge are integrated within hyper acute stroke practice, rather than applied retrospectively through reflection. By drawing on Carper and Chinn and Kramer’s patterns of knowing, and Herman’s trauma theory, this paper demonstrates how reflective practice actively shapes clinical judgement in time critical and emotionally complex settings. In doing so, it contributes to nursing theory by grounding epistemological concepts in lived practice and offers practical insight for nurses, educators and policymakers seeking to strengthen reflective capacity in acute care environments.

The contribution of nursing theory and knowledge to practice development

The philosophical exploration of knowledge has longstanding roots, influencing how disciplines construct and apply knowledge in practice. As nursing began to evolve during the early 1900s, fundamental knowledge specific to nursing values was sought out (Rutty, 1998). Within this context, Carper’s identification of four patterns of knowing marked a pivotal moment, offering structure through which nurses could interpret and apply knowledge in practice. The four ways of knowing that Carper developed were: empirical knowledge, personal knowledge, aesthetic knowledge and ethical knowledge (Carper, 1978). This framework, with the lexicon later expanded by Chinn and Kramer to include emancipatory knowing (Chinn and Kramer, 2008), can provide a foundation for understanding how reflective practice operates within contemporary stroke care.

Florence Nightingale has long been recognised as the starting point for professional nursing, with her unique focus on clarifying a distinction between nursing knowledge and medical knowledge (Alligood, 2022). Nursing is a profession with an expert knowledge base that is separate but also equal to that of the medical profession; therefore, highlighting that nursing is not just an occupational workforce (Borsay and Hunter, 2012). The contribution of nursing theory to professional practice over the last century cannot be understated, and attests to nursing being recognised as both a discipline and a profession.

Critical engagement with both theory and knowledge is therefore essential in nursing, as they are both interlinked, with reflective practice bridging the gap between theory and practice (Johnson and Webber, 2010; Sherwood, 2024). A comprehensive understanding of knowledge and theory enables nurses to combine technical competence with moral and emotional insight, an approach especially crucial within the emotionally charged environment of stroke care. Aggleton and Chalmers (2000: 1) stated that ‘without knowledge about the nature of people and their health-related needs, nurses would be unable to go about their work in anything but a haphazard way’. Integrating theory and knowledge, therefore, supports reflective and intentional nursing practice, particularly within complex and emotionally demanding clinical settings.

Patterns of knowing in nursing: from Carper to Chinn and Kramer

Chinn and Kramer’s patterns of knowing builds on Carper’s seminal four ways of knowing by adding emancipatory knowing (Chinn et al., 2022). This is an essential inclusion due to the need to understand how social injustices interact with wider determinants of health and their impact on health-related quality of life (Abu and Moorley, 2023). As a result, this addition to Carper’s work creates a more relevant framework when considering the modern issues and focus of the NHS and UK government to tackling social inequalities and injustices within healthcare (Morris and Robertson, 2024; Office for Health Improvement and Disparities, 2022). Within this section, Carper’s four ways of knowing and Chinn and Kramer’s fifth pattern of knowing will be critically discussed and applied to practice.

Carper’s patterns of knowing are often presented as theoretical categories; however, in practice, they are rarely used in isolation. Within the hyper acute stroke unit, these ways of knowing are engaged reflexively and simultaneously, often under significant time pressure. The following section therefore does not simply describe each pattern, but explores how they are recognised, prioritised and negotiated through reflective practice in real clinical encounters.

The first element of Carper’s patterns of knowing that will be explored is empirical knowing. Empirical knowing is scientific, factual and evidence-based (Chinn et al., 2022). It arises from what we can observe and is synthesised through systematic organisation into laws and theories (Carper, 1978). Practising in line with the best evidence forms part of the Nursing and Midwifery Council (NMC) code (Nursing and Midwifery Council, 2015), to which registered nurses practising in the United Kingdom must adhere. This underscores the need for nurses not only to be aware of the relevant evidence base but also to apply it to their practice. Although empirical knowledge is valuable in improving patient outcomes through evidence-based practices (Connor et al., 2023), it lacks a holistic and patient-centred approach to understanding patients’ ongoing needs. Furthermore, on reflection, a purely empirical approach to care risks overlooking patients’ lived experiences.

Aesthetic knowing is another form of knowing that Carper utilises, encompassing the idea of holistic care by anticipating how healthcare practices impact patients (Chinn et al., 2022). Aesthetic knowing, while not measurable, encompasses judgement to which empirical knowledge does not attain (Archibald, 2012). Nursing’s dual identity as both science and art is reflected in the relationship between empirical and aesthetic knowing (Lafferty, 1997). Empathy is a strong concept within aesthetic knowing, which as a result, allows nurses to understand patients’ lived experiences (Carper, 1978; Lafferty, 1997). It is not until nurses progress from taught theory into practice that one can truly grasp aesthetic knowing (Chinn et al., 2022; Lafferty, 1997). Although empirical knowing can be taught in a classroom and is easily accessible, aesthetic knowing takes time to master, but its importance to the nursing profession cannot be understated. Aesthetic knowing helps to bridge the gap where clinical guidance and emancipatory knowing cannot fully capture patients’ experience.

Personal knowing involves understanding and being aware of past experiences, reflecting on them to improve practice. Carper (1978) explained that personal knowledge is the hardest form of knowing to master, as it is difficult to teach and relies on experience to learn from. Nursing involves many disciplines, each with unique knowledge requirements, especially in specialist areas. Personal knowing draws on our ability to understand our own unique knowledge bases and utilise this in practice (Rutty, 1998). Personal knowing also allows nurses to reflect on practice to improve care and build practical, professional and interpersonal skills. In this section, it is important to note that reflecting on practice is part of the NMC code, which states that reflection should be used to improve practice and performance (Nursing and Midwifery Council, 2015). Reflection plays a key part in nursing, with reflective tools and theories used to identify knowledge gaps or improve the quality of care (Sherwood, 2024). Furthermore, distressing situations do occasionally arise and being able to reflect on them is fundamental to building resilience and emotional intelligence while reducing burnout and emotional fatigue.

Ethical knowing is the process of abiding by ethical standards and professional values (Chinn et al., 2022). Ethical knowing is not abstract but deeply embedded within daily nursing practice and requires nurses to integrate professional codes, legal frameworks and moral sensitivity. Ethical knowledge is often taught alongside empirical knowledge and forms a vital component of nursing practice (Chinn et al., 2022). However, ethical knowing alone fails to provide answers to complex moral decisions (Carper, 1978). Nurses must embrace empirical knowing, while also understanding ethical principles when best practice does not truly reflect individual patients’ requirements (Thorne, 2020).

The final pattern, emancipatory knowing, which was added by Chinn and Kramer in 2008, involves identifying and challenging the social, political and systemic structures that influence inequality (Chinn and Kramer, 2008). Through reflection of emancipatory knowing, nurses have the possibility of identifying their own misguided and firmly held perceptions of themselves and their roles, which in turn brings about change (Taylor, 2000: 148). Emancipatory knowing requires nurses not only to recognise these inequalities within their patient population but to act upon them. It also involves critical reflection on organisational and systemic disproportionality which affects vulnerable populations. Through emancipatory knowing, nurses contribute a more just and equitable model of care. Emancipatory knowing is teachable and can also be gained through experience.

Within stroke care, emancipatory knowing becomes particularly significant when considering the unequal distribution of stroke risk and outcomes. Patients from socioeconomically deprived backgrounds are more likely to experience stroke, present later to services and have reduced access to rehabilitation and ongoing support (Bray et al., 2018). Language barriers, health literacy and social isolation can further compound these inequalities, directly influencing patient outcomes. Emancipatory knowing therefore requires ongoing critical reflection, not only on patient circumstances but also on wider systems in which care is delivered. Although the ability to enact large-scale change may be limited within a hyper acute environment, small actions, such as adapting communication, involving family or advocating for patients, represent meaningful applications of this form of knowing. This raises questions about whether hyper acute systems, designed for efficiency, may unintentionally disadvantage those with complex social needs. In this way, emancipatory knowing becomes an active, practice-based process rather than a purely theoretical concept.

When brought together, the five patterns of knowing illustrate that no single form of knowing is sufficient in isolation; rather, they are interrelated and interdependent (Basford and Slevin, 2003). Although it could be argued that Chinn and Kramer’s framework has an abstract quality, the model provides a robust epistemological foundation for analysing how nurses construct, interpret and apply knowledge to practice. Therefore, rather than viewing these patterns of knowing as static categories, this paper positions them as reflective tools, actively drawn upon in the moment to shape judgement, relationship and care delivery in hyper acute stroke practice. This integration of multiple ways of knowing also provides a valuable foundation for understanding the emotional and psychological impact of stroke, which will be explored through Judith Herman’s trauma theory.

Reflecting on practice, the five patterns of knowing rarely occur in isolation; instead they are dynamically integrated within single patient encounters.

For example, when admitting a patient with a stroke:

Through reflection on-action, nurses can continuously negotiate these ways of knowing, asking not only what needs to be done, but what matters most to this patient in this moment.

Judith Herman’s three-stage trauma theory

Experiencing a stroke is a sudden, traumatic event (Stroke Association, 2013). As a result, healthcare professionals need an understanding of how to assist patients following this traumatic event, as having a stroke is associated with physical, social and psychological implications (Hole et al., 2014). Judith Herman published her seminal work, Trauma and Recovery, in 1992, outlining three key stages of trauma recovery (Herman, 1992; Zaleski, 2016). Although Herman’s work is grounded in psychological care of trauma victims (Zaleski, 2016), its wider application to trauma can be explored and applied aptly to stroke care. As a middle-range theory, Judith Herman’s trauma theory is sufficiently generalisable to inform clinical nursing practice, including stroke care. Herman’s trauma theory comprises three stages: establishing safety; remembrance and mourning; and reconnection and reintegration. To evaluate this theory and understand its relevance and usefulness to stroke care, it must be critically analysed.

Chinn and Kramer’s theory analysis model (2022) will be used to critically analyse Judith Herman’s three-stage trauma theory model. Chinn and Kramer’s theory analysis model utilises five reflective questions in order to critically analyse a theory. These questions encompass clarity, simplicity, generalisability, accessibility and importance (Chinn et al., 2022: 125):

These questions provide a structured reflective framework and are applied throughout the following analysis to evaluate the relevance and applicability of Herman’s theory within hyper acute stroke care.

Establishing safety is the first stage of Herman’s theory and involves minimising threat by focusing on controlling the body and later the surrounding environment (Herman, 2015). This is a clear and important step in the management of stroke due to time being one of the critical first steps in stroke management, with the mantra in stroke care being ‘Time is brain’ (World Stroke Organisation, 2024). Allowing patients to regain autonomy and medically stabilising patients is critical within a hyper acute setting. However, it must be noted that although the step is clear and appears simple, the accessibility of this first step is limited due to the short hospital stays on a hyper acute unit. From experience, patients and families often ask, ‘Am I going to be okay?’ This question highlights the importance of initial safety and the role that nurses have in utilising aesthetic knowing to comfort patients and their loved ones following trauma.

The second step of Herman’s theory is remembrance and mourning, which highlights the need to remember the self before and embrace the change that has developed (Herman, 2015). Post-stroke patients often experience identity change, loss of autonomy and physical function (Stroke Association, 2013). Although this stage of Herman’s theory is important, it can be a lengthy process that is practically constrained. This section of Herman’s theory is closely aligned with another psychological theory by Erik Erikson. Erikson developed a theory of the psychosocial stages of development, one of which was ‘Identity vs Role Confusion’ (Erikson, 1968). Erikson primarily developed this theory to explore childhood development and stated that each stage must be completed before moving on to the next; however, one may return to a stage (Upton, 2012). This highlights how many theories have been developed from other theories and are interlinked. One major barrier to this stage of Herman’s theory is time. High workload, environmental stress and complex situations leave little time for meaningful conversations with patients to understand their psychosocial needs.

The final stage of Herman’s theory is reconnection and reintegration. This stage is very important within stroke care as discharge is seen as a primary step towards rehabilitation (Rahmi et al., 2025). Reintegration can be very difficult for patients post-stroke, especially those with aphasia. Aphasia can limit one’s ability to socialise and can cause social isolation (Stroke Association, 2013). Reintegrating into society can strengthen social bonds and help patients regain their identity (Stroke Association, 2013). In my practice, small achievements, such as initial steps in physiotherapy, significantly enhance patients’ sense of independence and hope. However, social and economic factors influence reconnection and reintegration, highlighting the intersectionality with emancipatory knowing.

When critically reviewing Herman’s trauma theory, many strengths emerge. The theory provides a holistic overview, while drawing on a psychological framework that aligns well with nursing values and stroke care. It must also be acknowledged that the relation to Carper and Chinn and Kramer’s patterns of knowing is strong, which therefore gives this theory strength. While applying Chinn and Kramer’s theory analysis model to Herman’s theory, it becomes clear that overall, Herman’s theory is generalisable, simple, clear and notably is an important theory to apply to practice. There are limitations to this theory, such as patients moving back and forth between stages and not always completing one stage fully before transitioning to the next. This theory also may not account for the potentially long recovery that some stroke survivors experience or the urgency of a hyper acute setting. Despite these limitations, this theory remains highly relevant and a strong, applicable model for many different nursing settings.

Reflective insights from hyper acute stroke nursing

The integration of theory and knowledge into clinical practice has a profound influence on my role as a nurse working within a hyper acute stroke unit, particularly when supporting patients experiencing sudden loss, uncertainty and trauma. Carper and Chinn and Kramer’s patterns of knowing provide a valuable interpretive structure for understanding my decision-making. Herman’s three-stage trauma theory offers further depth in recognising the emotional and psychological needs of patients. However, although these theoretical frameworks enhance practice, they also highlight important limitations and barriers that contribute to the ongoing theory–practice gap. This section demonstrates how reflection is not separate from practice, but embedded within it.

Empirical knowing is highly visible in the hyper acute stroke unit, where clinical urgency necessitates rapid action based on evidence, guidelines and protocols. This form of knowing shapes much of my practice, particularly when completing neurological observations, escalating deteriorating patients or supporting time critical interventions and medications. However, when reflecting critically on the care of patients experiencing stroke, I recognise moments where empirical knowing dominates to the extent that it risks overshadowing other necessary knowledge forms, particularly during initial assessment and admission.

For example, while completing rapid neurological observations or preparing a patient for an urgent scan, opportunities to explain procedures or acknowledge patient distress may be limited. This demonstrates the tension between empirical and aesthetic knowledge, underscoring the need for balance and harmony between all forms of knowing. In the context of stroke care, this tension is particularly evident when patients present with communication difficulties such as aphasia, where distress may be expressed non-verbally and can easily be overlooked. Upon reflection, a critical question which I believe needs further answering is: Does strict adherence to protocols risk dehumanising nursing care?

Aesthetic knowing enables me to anticipate patient needs beyond observable symptoms. This is particularly relevant when patients give non-verbal signals, especially those with aphasia. Herman’s theory deepens my understanding within this form of knowing, as creating a safe environment is just as important as medical stability. In practice, this means ensuring patient needs are understood and anticipating what they might be. For patients experiencing stroke, this may involve recognising fear, confusion or frustration when they are unable to communicate effectively, and responding through reassurance, presence and adaption of communication strategies. As with empirical knowing, a major barrier is time. Having the time to spend with each patient can be a challenge, but with effective time management and prioritisation, this is possible.

Personal knowing further shapes my approach, as critical reflection on my practice is vital. Herman’s second stage is subtly observed as the internal struggles patients’ experience are often not externally expressed. However, engaging with this stage of Herman’s theory requires emotional awareness, which is gained through reflective practice. In stroke care, this is particularly relevant when patients begin to process the sudden loss of function or independence, which may not be immediately visible during acute admission. I recognise how rushed, task-orientated interactions can limit my grounded and emotional interactions and can cause patients to feel excluded from their care. However, when this stage of Herman’s theory and personal knowing is applied, I recognise the profound impact this can have on patients’ hospital experience.

Ethical and emancipatory knowing guide my practice through embracing respect and acknowledging social inequalities. Ethical challenges are frequently encountered in stroke care due to impaired capacity, rapid decision-making and the involvement of multiple care teams. Ethical knowing can also involve advocating for patients within the multidisciplinary team. People from deprived areas are at higher risk of stroke, with poorer health literacy, language barriers and a lack of social support also exacerbating disparities within healthcare (Bray et al., 2018). In practice, this may involve recognising when a patient requires additional support to understand their diagnosis or treatment, or advocating for early involvement of family members and support services.

I recognise that understanding emancipatory knowledge is important, but improvement needs to be made on how nurses can apply this area of knowing in practice and the extent to which they can bring about change. Reflecting on this, I recognise that these factors are not always immediately visible within the hyper acute setting, where the clinical priority is rapid stabilisation. However, even within these time-critical interactions, emancipatory knowing prompts me to question how underlying social factors may shape a patient’s experience of care. For example, a patient with limited health literacy may appear disengaged, when in reality they may not fully understand the information being communicated. Emancipatory knowing therefore requires more than awareness; it demands ongoing critical reflection on how one’s own practice may reproduce or challenge these inequalities.

Overall engaging with Chinn and Kramer’s five patterns of knowing and Herman’s three-stage trauma theory does enhance my practice and understanding of stroke care. Nursing practice is inherently knowledge-based, requiring nurses to integrate information from multiple sources and apply this understanding directly to complex clinical care (Peterson and Bredow, 2009). Although theory cannot always be applied perfectly in practice, it provides a strong foundation for advancing patient-centred and holistic care.

Conclusion

This paper has critically explored how knowledge and theory influence nursing practice. It has demonstrated that effective stroke care requires an integrated understanding of empirical evidence, ethical decision-making, emotional awareness and theoretical insight. The exploration of the historical development of nursing knowledge and theory has highlighted that the profession has evolved to form a unique and ubiquitous foundation of knowledge and theory. This process underpins contemporary expectations for nurses to engage critically with evidence, practice reflectively and deliver holistic, person-centred care.

Carper and Chinn and Kramer’s patterns of knowing provided an essential framework for understanding the varied nature of nursing knowledge. Together, these five patterns illustrated the interdependence of knowing forms and highlighted the importance of balance and reflexive practice. Judith Herman’s three-stage trauma theory contributed additional depth by framing stroke as not only a medical emergency but also a psychologically destabilising event. Considering safety, emotional processing and reconnection with society as essential aspects of recovery, supporting a more nuanced understanding of the patient journey. When placed alongside the five patterns of knowing, Herman’s work reinforced the need for nurses to engage with the psychosocial dimensions of stroke, aligning with holistic and trauma-informed care principles already valued within the profession.

Overall, this paper has shown that theoretical understanding and diverse forms of knowledge are not abstract academic constructs, but essential elements that actively shape safe, ethical and person-centred nursing. For nurses working within hyper acute stroke settings, integrating these frameworks offers a practical reflective approach to navigating the tension between urgency, uncertainty and person-centred care. Reflective practice is therefore central to nursing, not as reflection after care has ended, but as an active process that informs judgement, relationships and care in the moment.