NLN PRESS
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NURSING AS CARING
A Model for Transforming Practice
By Anne Boykin and Savina O. Schoenhofer
Anne Boykin, PhD, RN
Dean and Professor
Director, Christine E. Lynn
Center for Caring
College of Nursing
Florida Atlantic University
Boca Raton, Florida
Savina O. Schoenhofer, PhD
Professor of Graduate Nursing
Alcorn State University
Natchez, Mississippi
CONTENTS
ABOUT THE AUTHORS FOREWORD
PREFACE
INTRODUCTION
ACKNOWLEDGEMENTS
FOUNDATIONS OF NURSING AS CARING
NURSING AS CARING 11
NURSING SITUATION AS THE Locus OF NURSING 17
IMPLICATIONS FOR PRACTICE AND NURSING SERVICE ADMINISTRATION 23
IMPLICATIONS FOR NURSING EDUCATION 41
THEORY DEVELOPMENT AND RESEARCH 51
EPILOGUE 57
INDEX 65
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ABOUT THE AUTHORS
Anne Boykin, Ph.D, is Dean and Professor of the College of Nursing at
Florida Atlantic University in Boca Raton, Florida. She is also Director
of the Christine E. Lynn Center for Caring. This center is focused on
humanizing care in the community through the integration of teaching,
research, and service grounded in caring. Dr. Boykin is past President
of the International Association for Human Caring, a member of several
local boards, and is actively involved in various nursing organizations
at the national, state, and local levels. She has published and
consulted widely on caring in nursing. Currently, she and Dr.
Schoenhofer are engaged in a two-year funded demonstration project.
The purpose of this project is to demonstrate the value of a model for
health care delivery in an acute care setting that is intentionally
grounded in Nursing as Caring.
Savina O. Schoenhofer, Ph.D, is Professor of Graduate Nursing at Alcorn
State University in Natchez, Mississippi. Dr. Schoenhofer is co-founder
of the nursing aesthetics publication, Nightingale Songs. Her research
and publications are in the areas of everyday caring, outcomes of caring
in nursing, nursing values, nursing home management, and affectional
touch.
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FOREWORD
Marilyn E. Parker, PhD, RN, Professor of Nursing Florida Atlantic
University, Boca Raton, Florida
Caring may be one of the most often used words in the English language.
Indeed, the word is commonly used as much in talking about our everyday
lives and relationships as it is in the marketplace. At the same time,
nurses thinking about, doing, and describing nursing know that caring
has unique and particular meaning to them. Caring is one of the first
synonyms for nursing offered by nursing students and is surely the most
frequent word used by the public in talking about nursing. Caring is an
essential value in the personal and professional lives of nurses. The
formal recognition of caring in nursing as an area of study and as a
necessary guide for the various avenues of nursing practice, however,
is relatively new. Anne Boykin and Savina Schoenhofer have received
many requests from academic peers and students to articulate the nursing
theory they have been working to develop. This book is a response to
the call for a theory of nursing as caring. The progression of nursing
theory development often has been led by nurse theorists who stepped
into other disciplines for ways to think about and study nursing and for
structures and concepts to describe nursing practice. The opportunity to
use language and methods of familiar, relatively established bodies of
knowledge that could be communicated and widely understood took shape as
many nursing scholars received graduate education in disciplines outside
of nursing. Conceptions and methods of knowledge development often came
then from disciplines in the biological and social sciences and were
brought into ways of thinking about and doing nursing scholarship.
Evolution of new worldviews opened the way for nurses to develop
theories reflecting ideas of energy fields, wholeness, processes, and
patterns. Working from outside the discipline of nursing, along with
shifts in worldviews, has been essential to opening the way for nurses
to explore nursing as a unique practice and body of knowledge from
inside the discipline, and to know nursing in unprecedented ways.
Nursing as Caring: A Model for Transforming Practice sets forth a
different order of nursing theory. This nursing theory is personal, not
abstract. In order to express nursing as caring there is a clear need to
know self as caring person. The focus of the Nursing as Caring theory,
then, is not toward an end product such as health or wellness. It is
about a unique way of living caring in the world. It is about nurses and
nursed living life and nurturing growing humanly through participation
in life together.
Nursing as caring sets forth nursing as a unique way of living caring in
the world. This theory provides a view that can be lived in all nursing
situations and can be practiced alone or in combination with other
theories. The domain of nursing is nurturing caring. The integrity, the
wholeness, and the connectedness of the person simply and assuredly is
central. As such, this is perhaps the most basic, bedrock, and therefore
radical, of nursing theories and is essential to all that is truly
nursing.
The dynamic, living idea of nursing as caring must be expressed
knowledgeably. Perhaps for this reason, the book presents the essence of
the idea and encourages its careful study and understanding in full hope
for further development. In this regard, many questions come to mind
in thinking about this work and its importance for the discipline and
practice of nursing.
* What distinguishes this nursing theory from others?
* In what ways does this work add to the body of nursing knowledge?
* In what new and distinct ways are we to view theories of our discipline and practice?
* What are new descriptions of processes for development, study, and appraisal of nursing theories?
* How will new relationships among nursing theories be discovered and described?
As earlier theorists brought words and ways of other bodies of knowledge
to help nurses know and articulate nursing, so some of the language of
this new theory has been drawn from philosophy. Generally, the language
used to express the theory of nursing as caring is everyday language.
This model is a clear assertion of and for nursing--it distinguishes
nursing knowledge, questions, and methods from those of other
disciplines. It helps us explore ways to use nursing knowledge and
knowledge of other disciplines in ways appropriate to nursing. This
volume offers rich illustrations of nursing that will immediately seem
familiar to most nurses. Many nurses will come to know new possibilities
for nursing practice, teaching, administration, and inquiry more fully.
In trying to open the door of this book and invite the reader to explore
the Nursing as Caring model, I am personally aware that the living of
nursing and the commitment nursing calls forth cannot be fully measured.
Each of us is part of the ongoing creation of nursing as we share our
experience of nursing. These attempts to share our nursing are a major
part of the development of nursing as a discipline and professional
practice. Our expressions about nursing are continually challenged as
part of the creating process.
The processes of theory development have been the ongoing gift of many
nursing scholars, theorists, and researchers. In expressing this new
theory of Nursing as Caring, nurses have again courageously stepped
forward to develop, articulate, and publish ideas that seem very new to
many, and in doing so have risked to offer opportunity for a full range
of responses to this work. I know Anne Boykin and Savina Schoenhofer
invite with great anticipation responses from nurses and will appreciate
opportunity for dialogue.
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PREFACE
'The ideas which led to the development of theory of Nursing as Caring
have their beginnings in our personal histories and came together when
we met in 1983. As we participated in the work of establishing nursing
as an academic discipline and creating a nursing curriculum grounded in
caring at Florida Atlantic University, each of us learned to value the
special insights brought by the other. We also discovered early on that
we shared a deep devotion to nursing--to the idea of nursing, to the
practice of nursing, to the development of nursing.
Several years ago, we realized that our thinking had developed to the
extent that we were working with more than a concept. Although we
are well aware of an ongoing debate in nursing over technical versus
philosophical connotations of theory, we characterize our work as a
general theory of nursing developed in the context of our understanding
of human science. While we are familiar with the formal concept of
theory used in disciplines grouped in the physical and natural sciences,
we believe that mathematical form is not an appropriate model for theory
work in the discipline of nursing. Therefore, we do not present our
work in the traditional form of concepts, definitions, statements, and
propositions, but have struggled to find ways to preserve the integrity
of nursing as caring through our expressions.
Our thinking has been particularly influenced by the work of two
scholars, Mayeroff and Roach. Both of these authors have given voice to
caring in important ways--Mayeroff in terms of generic caring, and Roach
in terms of caring person as well as caring in nursing. We are aware of
other influences on our understanding of caring and caring in nursing,
including Paterson and Zderad, Watson, Ray, Leininger, and Gaut. Our
conception of nursing as a discipline has been directly influenced by
Phenix, King and Brownell, and the Nursing Development Conference
Group. While this is not an exhaustive listing of the scholars who have
contributed to the development of our ideas, we have made a deliberate
effort to review the evolution of our thinking and to recognize
significant specific contributions.
Chapter 1 presents a discussion of key ideas that ground and
contextualize nursing as caring. The most fundamental idea is that
of person as caring with nursing conceptualized as a discipline. Our
understanding of this foundation has been seasoned both from within
nursing and from outside the discipline, but always with the purpose of
deepening our understanding of nursing. When we have gone outside the
discipline to extend possibilities for understanding, we have made an
effort to go beyond application, to think through the nursing relevance
of ideas that seemed, on the surface, to be useful. Chapter I and
subsequent chapters draw on Mayeroff's (1971) caring ingredients,
including:
* Knowing--Explicitly and implicitly, knowing that and knowing how,
knowing directly, and knowing indirectly (p. 14).
* Alternating rhythm--Moving back and forth between a narrower and a
wider framework, between action and reflection (p. 15).
* Patience--Not a passive waiting but participating with the other,
giving fully of ourselves (p. 17).
* Honesty--Positive concept that implies openness, genuineness, and
seeing truly (p. 18).
* Trust--Trusting the other to grow in his or her own time and own way
(p. 20).
* Humility--Ready and willing to learn more about other and self and what
caring involves (p, 23).
* Hope--"An expression of the plentitude of the present, alive with a
sense of a possible" (p. 26).
* Courage--Taking risks, going into the unknown, trusting (p. 27).
In Chapter 2, we present the theory in its most general form. We have
resisted the temptation to include examples in this chapter for two
reasons: first, because an example always seemed to lead to the need to
further explain and illustrate; and second, because we wished to have
a general expression of the theory, undelimited by particulars, and
available to facilitate further theory development.
Chapter 3 elaborates on the idea of the nursing situation, and
illustrates the practical meaning of the theory in a range of particular
nursing situations. This chapter will probably be most satisfying to
the reader whose everyday nursing discourse is that of nursing practice.
Some might find it useful to read this chapter first, before reading
Chapters 1 and 2.
In Chapter 4, we explore the practice of nursing as caring and discuss
nursing service administration from the perspective of the theory.
Chapter 5 addresses issues and strategies for transforming nursing
education and nursing education administration based on nursing as
caring.
Our understanding of nursing as a human science discipline is the
central focus of Chapter 6. In this chapter, we discuss the necessity
of transforming models of nursing inquiry to facilitate the further
development of nursing knowledge in the context of the theory of Nursing
as Caring. We also share our commitment to the ongoing development
of nursing as caring and directions we wish to take in living that
commitment.
It has been our intention to organize and communicate the initial,
comprehensive presentation of Nursing as Caring usefully for nurses in
practice, as well as those in administrative and academic roles. We
have benefited wonderfully from the dialogue resulting from formal and
informal opportunities to share this work as it evolved. We look forward
to continuing this dialogue. Anne Boykin, PhD, RN Dean and Professor
College of Nursing Florida Atlantic University Boca Raton, FL Savina
Schoenhofer, PhD Professor of Graduate Nursing Alcorn State University
Natchez, MS REFERENCE Mayeroff, M. (1971). On Caring. New York: Harper
and Row.
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INTRODUCTION
The study of human caring as a unique and essential characteristic
of nursing practice has gradually expanded from early definitional,
philosophical, and cultural research on the meanings of caring, to the
explication of theoretical definitions of caring, conceptual models,
proposed taxonomy of caring concepts, a great deal of creative
experimentation with research methodologies, and the development of
several theories of caring.
In general, one may say that knowledge of caring has grown in two ways,
first by extension and, more recently, by intension. Growth by extension
consists of a relatively full explanation of a small region which is
then carried over into an explanation of adjoining regions. Growth by
extension can be associated with the metaphors of building a model or
putting together a jigsaw puzzle (Kaplan, 1964, p. 305).
In growth by intension, a partial explanation of a whole region is
made more and more adequate and outlines for subsequent theory and
observation are clarified. Growth by intension is associated with the
metaphor of gradually illuminating a darkened room. A few persons enter
the room with their individual lights and are able to slowly perceive
what is in that room. As more persons enter the room, it becomes more
fully illuminated, and the observed reality is clarified (Kaplan, 1964,
p. 305).
Growth by extension is implicit in the early caring definitions,
explications, and models. The knowledge about caring was built up
piece-by-piece, in the first ten years of study, by a few nurse scholars
committed to the study of human care and caring.
Today, some fifteen years later, progress in the study of the caring
phenomenon is no longer piecemeal but gradual and on a larger scale,
with illumination from the works that have preceded. Growth by
intension is evidenced by the development of an extant bibliography,
categorization of caring conceptualizations, and the further development
of human care/caring theories. Although the concept of caring has not
been definitively and exhaustively explored, the understanding of the
broad-scale phenomena of human care and caring has become enlarged. A
review of the caring literature by Smerke (1989) and an analysis of the
nursing research on care and caring by Morse, Bottoroff, Leander, and
Solberg (1990) now provides researchers with an interdisciplinary
guide to human caring literature and a categorization of five major
conceptualizations of caring: (1) a human trait, (2) a moral
imperative, (3) an affect, (4) an interpersonal interaction, and (5)
an intervention. There is now a body of knowledge about care and caring
that can be used to further develop new knowledge through subsequent
theory and research.
The Boykin and Schoenhofer work, Nursing as Caring: A Model for
Transforming Practice, is an excellent example of growth by intension.
Utilizing previous caring research, caring theory, and personal
knowledge, the authors have put forth a theory that will not only
increase the content of caring knowledge but will also change its form.
A new theory adds some knowledge and it transforms what was previously
known, clarifying it and giving it new meaning as well as more
confirmation. The whole structure of caring knowledge changes with
growth, even though it is recognizably similar to what it has been. As
one reads this theory, many of the assumptions presented seem familiar,
perhaps because the authors realized that caring theory could best be
understood in both its historical and immediate context.
The historical context of the systematic study, explication, and
theorizing about human care and caring phenomena in nursing began some
twenty years ago with the early work of Madeleine Leininger. The first
structural stones were laid by a group of nurse researchers who met for
the first time in 1978 at a conference convened by Dr. Leininger at
the University of Utah in Salt Lake City. Some sixteen enthusiastic
participants underscored the need for continued in-depth thinking and
for sharing scholarly ideas about the phenomena and nature of caring.
Plans were made to continue with yearly research conferences focused on
four major goals:
1. The identification of major philosophical, epistemological, and
professional dimensions of caring to advance the body of knowledge that
constitutes nursing.
2. Explication of the nature, scope, and functions of caring and its
relationship to nursing care.
3. Explication of the major components, processes, and patterns of
care or caring in relationship to nursing care from a transcultural
perspective.
4. Stimulation of nurse scholars to systematically investigate care
and caring and to share their findings with others. These four goals,
developed by the members of the Caring Research Conference Group,
provided nurse scholars with a direction for caring research that
yielded a substantial piece of research-based literature.
The first ten years of the Conference group (1978-1988) witnessed a
great deal of diverse and stimulating research. Major philosophical
dimensions of caring were explicated in the works of Bevis (1981), Gaut
(1984), Ray (1981), Roach (1984), and Watson (1979)
Explication of major components, processes, and patterns of care or
caring from a transcultural perspective was first developed in the early
work of Aamodt (1978) and Leininger (1978, 1981), to be followed by the
works of Baziak-Dugan (1984), Boyle (1984), Guthrie (1981), Wang (1984),
and Wenger and Wenger (1988).
Another group of nurse researchers chose to study the concept of care
and caring concomitantly with nursing care practices. Brown (1982),
Gardner and Wheeler (1981), Knowlden (1985), Larson (1981, 1984),
Riemen (1984, 1986), Sherwood (1991), and Wolf (1986) investigated nurse
behaviors perceived by patients and nurses as indicators of caring and
noncaring in an attempt to further develop the essential structure of a
caring interaction.
Watson, Bruckhardt, Brown, Block, and Hester (1979) proposed an
alternative health care model for nursing practice and research. After
seven years of implementation experience using a clinical practice model
with various hospitals, Wesorick (1990) presented a model that supported
caring as a practice norm in hospital settings.
Administrative caring within an institutional or organizational culture
was the research focus for Nyberg (1989), Ray (1984, 1989), Valentine
(1989, 1991), and Wesorick (1990, 1991). Caring within educational
settings and in the teacher-learner relationship also received attention
by Bevis (1978), Bush (1988), Condon (1986), and MacDonald (1984).
Research methodologies became a focus of study as investigators
struggled with how best to study nurse caring phenomena: Boyle (1981),
Gaut (1981, 1985), Larson (1981), Leininger (1976), Ray (1985), Riemen
(1986), Swanson-Kauffman (1986), Valentine (1988), Watson (1985), and
Wenger (1985).
By the 1980s, it became clear that the systematic study of human care
and caring as a distinct feature of the profession of nursing had
evolved globally. Dunlop (1986), from Australia, asked: "Is a science of
caring possible?" Bjrn (1987) described the caring sciences in Denmark,
and Eriksson (1987, 1992) began to develop her theories of caring as
communion, and caring as health. Kleppe (1987) discussed the background
and development of caring research in Norway. Flynn (1988) compared
the caring communities of nursing in England and the United States.
Halldorsdottir (1989, 1991), from Iceland, developed research on caring
and uncaring encounters in nursing practice and in nursing education.
The early endeavors of the first nurse researchers who focused on caring
laid out the lines and clarified the observable realities for subsequent
research and theorizing. The production of nursing theory is dependent
on an intellectual apprehension of the movement between the concrete
realities of nursing practice and the abstract world of those
assumptions and propositions known as theories (Benoliel, 1977, p.
110). The creation of new knowledge rests on some known assumptions, and
Boykin and Schoenhofer's theory builds on the work of three other nurse
scholars who have developed theories of caring in nursing, each with
a differing apprehension of the realities of human care and caring:
Madeline Leininger from an anthropological perspective--one of the first
nurse theorists to focus on caring as the essence of nursing practice;
Sister M. Simone Roach, who provides a philosophical and theological
perspective; and Jean Watson from an existential, philosophical
perspective.
The significance of Leininger's Culture-Care Theory (1993) is in the
study of human care from a transcultural nursing perspective. This focus
has led to new and unique insights about care and the nature of caring
and nursing in different cultures, and has developed the knowledge so
essential to providing culturally sensitive nursing care throughout the
world.
Roach's work, The Human Act of Caring (1984, 1992) is recognized as one
of the most substantive, insightful, and sensitive publications on human
caring. Her ultimate conclusion after years of study and reflection is:
"Caring is the human mode of being."
Watson, in her theory of human care (1985, 1989), addressed the issue
of nursing as a humanistic science rather than a formal or biological
science. This perspective was an essential paradigm shift for nursing
knowledge, but essential for study of the caring phenomena. Within this
context, Watson developed a theory of caring in nursing that involves
values, a will and a commitment to care, knowledge, caring actions, and
consequences. Caring then becomes a moral imperative for practitioners
of the profession of nursing.
Boykin and Schoenhofer's theory comes not only from "what is known about
caring" but also from their imagination and creative sense of "what
could be known." They suggest a context for personal theorizing about
caring experiences, trusting that each person will examine the
content of those experiences as a sequence of more or less meaningful
events--meaningful both in them and in the patterns of their occurrence.
The authors put forth a framework for just such reflection, and they
challenge practicing nurses to "come to know self as caring person in
ever deepening and broadening dimensions."
If science has to do with knowing and that which is known, then theory
is about knowledge production. In one sense of the term, theory activity
might well be regarded as most important and distinctive for human
beings because is stands for the symbolic dimension of experience
(Kaplan, 1964, p. 294).
Boykin and Schoenhofer's work invites all nurses to develop nursing
knowledge and to theorize from within the nursing situation. The
invitation requests a sharing of both content and context of nursing
experiences as they are lived in meaningful patterns that have
significant bearings on all other patterns. To engage in theorizing
means not only to learn by experience, but to learn from experience--that
is, to take thought about what is there to be learned (Kaplan, 1964, p.
295).
In the thinking of Alfred North Whitehead (1967), theory functions
not to allow prediction but to provide a frame of reference, a pattern
through which one can discern particulars of any given situation. Theory
in this sense permits attendance or focus by giving form to otherwise
unstructured content. The proposed theory, Nursing as Caring: A Model
for Transforming Practice, provides the context. The frame of reference
through which any nurse engaged in a shared lived experience of
caring can not only interpret the experience but also can perceive and
symbolically express the patterns of nurse caring. The perception
of patterns will give the readers and listeners a "click of
meaningfulness," and the explanation will be the discovery of
interconnections among patterns. The perception that everything is just
where it should be to complete the pattern is what gives us intellectual
satisfaction and provides the context or focus for the one aspect of
reality that is the essence of nursing-caring.
Delores A. Gaut, PhD, RN Immediate Past President International
Association of Human Caring, Inc. Visiting Professor University of
Portland School of Nursing Portland, Oregon
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ACKNOWLEDGEMENTS
The authors gratefully acknowledge past and present faculty and students
at the College of Nursing at Florida Atlantic University whose sharing
through dialogue has contributed to the evolution of ideas over the past
12 years. We are particularly grateful to the faculty for taking the
risks necessary to advance a program of study grounded in the discipline
with caring as the focal point. Through supporting each other as
colleagues, we were able to suspend our traditional pasts in order to
study and teach the discipline with a new lens.
We also are indebted to students and colleagues whose questions,
stories, and expressions of nursing fostered clarity in our
understanding of the ontology of nursing. A special thank you goes to
the following colleagues whose stories are re-presented in this book:
Gayle Maxwell, Daniel Little, Sheila Carr, Patricia Kronk, Lorraine
Wheeler, and Michele Stobie.
To the many scholars in the discipline whose works reflect a commitment
to the development of nursing knowledge related to caring in nursing,
and especially to the members of the International Association of Human
Caring, we thank you. We extend a special thanks to Marilyn Parker and
Terri Touhy for their unending devotion and commitment to nursing and
for the blessing of their friendship.
We acknowledge Shawn Pennell who designed the image of the dance of
caring persons described in this book. Sally Barhydt of the National
League for Nursing offered understanding and thoughtful input in
the early stages of this process and we thank her for her invaluable
support. Thanks also to Allan Graubard of the League for his recognition
of the meaning of our work, and for his careful attention in seeing this
manuscript through to publication.
We would like to recognize all persons we have been privileged to
nurse. Through the experience and study of these nursing situations, the
knowledge of the discipline unfolds.
Last, we extend gratitude to our families for living caring with us and
supporting our many professional endeavors.
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CHAPTER I -- FOUNDATIONS OF NURSING AS CARING
In this chapter we present the fundamental ideas related to person as
caring and nursing as a discipline and profession that serves as the
perspectival grounding for the theory Nursing as Caring. We intend
to offer our perspective of these ideas as influenced by the works of
various scholars so that the grounding for Nursing as Caring will be
understood. We do not intend to offer a novel perspective of the notion
of person, or a new generic understanding of caring or of discipline
and profession, but to communicate some of the ideas basic to Nursing as
Caring.
Major assumptions underlying Nursing as Caring include:
* persons are caring by virtue of their humanness
* persons are caring, moment to moment
* persons are whole or complete in the moment
* personhood is a process of living grounded in caring
* personhood is enhanced through participating in nurturing
relationships with caring others
* nursing is both a discipline and a profession
PERSPECTIVE OF PERSONS AS CARING
Throughout this book the basic premise presides: all persons are caring.
Caring is an essential feature and expression of being human. The belief
that all persons, by virtue of their humanness, are caring establishes
the ontological and ethical ground on which this theory is built.
Persons as caring is a value which underlies each of the major concepts
of Nursing as Caring and is an essential idea for understanding this
theory and its implications. Being a person means living caring, and it
is through caring that our "being" and all possibilities are known to
the fullest. Elaboration on the meaning of this perspective will provide
a necessary backdrop for understanding ideas in subsequent chapters.
Caring is a process. Each person, throughout his or her life, grows in
the capacity to express caring. Said another way, each person grows in
his or her competency to express self as caring person. Because of our
belief that each person is caring and grows in caring throughout life,
we will not focus on behaviors considered noncaring in this book. Our
assumption that all persons are caring does not require that every act
of a person necessarily be caring. There are many experiences of life
that teach us that not every act of a person is caring. These acts
are obviously not expressions of self as caring person and may well
be labeled noncaring. Developing the fullest potential for expressing
caring is an ideal. Notwithstanding the abstract context of this ideal,
it is knowing the person as living caring and growing in caring that
is central to our effort in this book. Therefore, even though an act or
acts may be interpreted as noncaring, the person remains caring.
While this assumption does not require that every act be understood as
an expression of caring, the assumption that all persons are caring does
require an acceptance that fundamentally, potentially, and actually each
person is caring. Although persons are innately caring, actualization of
the potential to express caring varies in the moment and develops
over time. Thus, caring is lived moment to moment and is constantly
unfolding. The development of competency in caring occurs over a
lifetime. Throughout life we come to understand what it means to be a
caring person, to Live caring, and to nurture each other as caring.
Roach and Mayeroff provide some explanation as to what caring involves.
Roach in her works (1984, 1987, 1992) has asserted that caring is the
"human mode of being" (1992, p. ix). As such, it entails the capacity
to care, the calling forth of this ability in ourselves and others,
responding to something or someone that matters and finally actualizing
the ability to care (192, p. 47). Since caring is a characteristic of
being human, it cannot be attributed as a manifestation of any single
discipline. These beliefs have directly influenced our assumption that
all persons are caring. Mayeroff, a philosopher, in his 1971 book On
Caring, discusses caring as an end in itself, an ideal, and not merely a
means to some future end. Within the context of caring as process, Roach
(1992, 1984) says that caring entails the human capacity to care, the
calling forth of this ability in ourselves and others, the responsivity
to something or someone that matters, and the actualizing of the
power to care. Even though our human nature is to be caring, the full
expression of this varies with the lived experience of being human.
The process of bringing forth this capability can be nurtured through
concern and respect for person as person.
Mayeroff suggests that caring "is not to be confused with such meanings
as wishing well, liking, comforting, and maintaining . . . it is not
an isolated feeling or a momentary relationship" (p. 1). He describes
caring as helping the other grow. In relationships lived through caring,
changes in the one who cares and the one cared for are evident. Mayeroff
tells us how caring provides meaning and order: In the context of a
man's life, caring has a way of ordering his other values and activities
around it. When this advising is comprehensive, because of the
inclusiveness of his caring, there is a basic stability in his life;
he is "in place" in the world instead of being out of place, or merely
drifting on endlessly seeking his place. Through caring for certain
others, by serving them through caring a man lives the meaning of his
own life. In the sense in which a man can ever be said to be at home
in the world, he is at home not through dominating, or explaining, or
appreciating, but through caring and being cared for (1971, p. 2).
Mayeroff expressed ideas about the meaning of being a caring person when
he referred to trust as "being entrusted with the care of another" (p.
7). He spoke of both "being with" the other (p. 43) and "being for" (p.
42) the other, experiencing the other as an extension of self and at the
same time "something separate from me that I respect in its own right"
(p. 2). To be a caring person means to "live the meaning of my own life"
(p. 72), having a sense of stability and basic certainty that allows an
openness and accessibility, experiencing belonging, living congruence
between beliefs and behavior, and expressing a clarity of values that
enables living a simplified rather than a cluttered life.
Watson, a nursing theorist and philosopher, offers insight into caring.
In her theory of Human Care, she examines caring as an intersubjective
human process expressing respect for the mystery of being-in-the-world,
reflected in the three spheres of mind-body-soul. Human care
transactions based on reciprocity allow for a unique and authentic
quality of presence in the world of the other. In a related vein, Parse
(1981) defines the ontology of caring as "risking being with someone
toward a moment of joy." Through being with another, connectedness
occurs and moments of joy are experienced by both.
If the ontological basis for being is that all persons are caring
and that by our humanness caring is, then I accept that I am a caring
person. This belief that all persons are caring, however, entails a
commitment to know self and other as caring person. According to Trigg
(1973), commitment "presupposes certain beliefs and also involves a
personal dedication to the actions implied by them" (p. 44). Mayeroff
(1971) speaks of this dedication as devotion and states "devotion is
essential to caring .. . when devotion breaks down, caring breaks down"
(p. 8). Mayeroff also states that "obligations that derive from devotion
are a constituent element in caring" (p. 9). Moral obligations arise
from our commitments; therefore, when I make a commitment to caring as a
way of being, I have become morally obligated. The quality of the moral
commitment is a measure of being "in place" in the world. Gadow (1980)
asserts that caring represents the moral ideal of nursing wherein the
human dignity of the patient and nurse is recognized and enhanced.
As individuals we are continually in the process of developing
expressions of ourselves as caring persons. The flow of life experiences
provides ongoing opportunities for knowing self as caring person. As
we learn to live fully each of these experiences, it becomes easier
to allow self and others the space and time to develop innate caring
capabilities and authentic being. The awareness of self as caring person
calls to consciousness the belief that caring, is lived by each person
moment to moment and directs the "oughts" of actions. When decisions are
made from this perspective, the emerging question consistently is, "How
ought I act as caring person?"
How one is with others is influenced by the degree of authentic
awareness of self as caring person. Caring for self as person requires
experiencing self as other and yet being one with self, valuing self
as special and unique, and having the courage, humility, and trust to
honestly know self. It takes courage to let go of the present so that it
may be transcended and new meaning be discovered. Letting go, of course,
implies a freeing of oneself from present constraints so that we may see
and be in new ways. One who cares is genuinely humble in being ready and
willing to know more about self and others. Such humility involves the
realization that learning is continuous and the recognition that each
experience is unique. As my commitment to persons as caring moves into
the future, I must choose again and again to ratify it or not. This
commitment remains binding and choices are made based on devotion to
this commitment.
Personhood is the process of living grounded in caring. Personhood
implies living out who we are, demonstrating congruence between beliefs
and behaviors, and living the meaning of one's life. As a process,
personhood acknowledges the person as having continuous potential for
further tapping the current of caring. Therefore, as person we are
constantly living caring and unfolding possibilities for self as caring
person in each moment. Personhood is being authentic, being who I am
as caring person in the moment. This process is enhanced through
participation in nurturing relationships with others.
The nature of relationships is transformed through caring. All relations
between and among persons carry with them mutual expectations. Caring
is living in the context of relational responsibilities. A relationship
experienced through caring holds at its heart the importance of
person-as-person. Being in the world also mandates participating in
human relationships that require re-sponsibility--responsibility to self
and other. To the extent that these relationships are shaped through
caring, they are consistent with the obligations entailed in relational
responsibility, and the "person-al" (person-to-person) relationships.
When being with self and others is approached from a desire to know
person as living caring, the human potential for actualizing caring
directs the moment.
All relationships are opportunities to draw forth caring possibilities,
opportunities to reinforce the beauty of person-as-person. Through
knowing self as caring person, I am able to be authentic to self and
with others. I am able to see from the inside what others see from
the outside. Feelings, attitudes, and actions lived in the moment are
matched by an inner genuine awareness. The more I am open to knowing
and appreciating self and trying to understand the world of other,
the greater the awareness of our interconnectedness as caring persons.
Knowing of self frees one to truly be with other. How does one come to
know self as caring person? Mayeroff's (1971) caring ingredients are
useful conceptual tools when one is struggling to know self and others
as caring. These ingredients include: honesty, courage, hope, knowing
(both knowing about and knowing directly), trust, humility, and alternating
rhythm. The idea of a hologram serves as a way of understanding
self and other. Pri-bram (1985) offers us an interesting view on
relationships in his discussion of hologram. He states that the
uniqueness of a hologram is such that if a part (of the hologram) is
broken, any part of it is capable of reconstructing the total image
(p. 133). Using this idea, if the lens for "being" in relationships is
holographic, then the beauty of the person will be retained. Through
entering, experiencing, and appreciating the world of other, the nature
of being human is ore fully understood. The notion of person as whole or
complete expresses an important value. As such, the respect for the total
person--all that is in the moment--is communicated. Therefore, from a
holographic perspective, it is impossible to focus on a part of a person
without seeing the whole person reflected in the part. The wholeness
(the fullness of being) is forever present. Perhaps in some context, the
word part is incongruent with this notion that there is only wholeness.
The term aspect, or dimension, may be a useful substitute.
The view of person as caring and complete is also intentional; it offers
a lens for a way of being with another that prevents the segmenting
of that other into component parts (e.g., mind, body, spirit). Here,
valuing and respecting each person's beauty, worth, and uniqueness is
lived as one seeks to understand fully the meaning of values, choices,
and priority systems through which values are expressed. The inherent
value that persons reflect and to which they respond is the wholeness
of persons. The person is at all times whole. The idea of wholeness does
not negate an appreciation of the complexity of being. However, from the
perspective of the theory Nursing as Caring, to encounter person as less
than whole involves a failure to encounter person. Un-il our view is
such that it includes the whole as complete person and not just a part,
we can not fully know the person. Gadow's (1984) contrasting paradigms,
empathic and philanthropic, are relevant to this understanding. The
philanthropic paradigm enables a relationship in which dignity is
bestowed as a "gift from one who is whole to one who is not" (p.
68). Philanthropy marks the person as other than one like me. Gadow's
empathic paradigm, on the other hand, "breaches objectivity" (p. 67) and
expresses participating in the experience of another. In the empathic
paradigm, the subjectivity of the other is "assumed to be as whole and
valid as that of the caregiver" (p. 68). These paradigm descriptions
facilitate our knowing how we are with others. Is the attitude expressed
through nursing one of person as part or person as whole? How do these
perspectives direct nursing practice?
Our understanding of person as caring centers on valuing and celebrating
human wholeness, the human person as living and growing in caring, and
active personal engagement with others. This perspective of what it
means to be human is the foundation for understanding nursing as a human
endeavor, a person-to-person service, a human social institution, and a
human science.
Our view enables the development of nursing as a discipline of constant
discovery and new knowing.
Like disciplines, professions have unique characteristics, as defined
by Flexner. Flexner (1919) initially identified as the most basic
characteristic of a profession that it addresses a unique and urgent
social need through techniques derived from a tested knowledge base.
Professions have their historical roots in those human services that
people provided for each other within existing social institutions
(e.g., tribe, family, or community). Thus, each profession, including
nursing, has its origins in everyday human situations and the everyday
contributions people make to the welfare of others. Flexner's founding
conditions for the designation profession are reiterated in the American
Nursing Association's 1980 Social Policy Statement, in which the idea of
a social contract is addressed.
Nursing: A Social Policy Statement was intended to provide nurses with
a fresh perspective on practice while providing society with a view of
nursing for the 1980s. The overall intent of this document was to call
to consciousness the linkages between the profession and society. While
the Social Policy Statement is considered by many (see, for example,
Rodgers, 1991; Packard & Polifroni, 1991; Allen, 1987; White, 1984) to
be outdated, we find the concept of the social contract to be useful
when studying the relationship of nurse to nursed. As the foundation
for professions, the social contract, while understood to be an
"hypothetical ideal" (Silva, 1983, p. 150), is also an expression of
a people recognizing (1) the presence of a basic need and (2) the
existence of greater knowledge and skill available to meet that need
than can be readily exercised by each member of the society. Society
at large then calls for commitment by a segment of society to the
acquisition and use of this knowledge and skill for the good of all.
Social goods are promised in return for this commitment.
Today, the profession of nursing is moving from a social contract
relationship toward a covenantal relationship between the nurse and
nursed. While the social contract implies an impersonal, legalistic
stance, the covenantal relationship emphasizes personal engagement and
ever present freedom to choose commitments. Cooper (1988), for example,
discusses her ideas on the relevance of covenantal relationships for
nursing ethics. She states "the promissory nature of the covenant
is contained in the willingness of individuals to enter a covenental
relationship" (p. 51) and it is within this context that obligations
arise. As caring persons, we "see" relationship (covenant) and honor
the bond between self and other. The ultimate knowledge gained from this
perspective is that we are related to one another (and to the universe)
and that harmony (brotherhood and sisterhood) is present as we live out
caring relationships.
Concepts of discipline and profession have been dismissed by critical
theorists as oppressive, anachronistic, and paternalistic (Allen, 1985;
Rodgers, 1991). In our study however, as we have explored essential
meanings of these concepts, we have found that they express fundamental
values congruent with cherished nursing values. Although we can agree
with critical theorists that discipline and profession have been
misused, perhaps too frequently, as tools of social elitism and
oppression, this misuse remains inappropriate because it violates the
covenantal nature of discipline and profession.
The discipline of nursing attends to the discovery, creation,
structuring, testing, and refinement of knowledge needed for the
practice of nursing. Concomitantly, the profession of nursing attends
to the use of that knowledge in response to specific human needs.
Certainly, the basic values communicated in the concepts of discipline
and profession are resonate with fundamental nursing values and
contribute to a fuller understanding of nursing as caring. Included
among those shared values are commitment to something that matters,
sense of persons being connected in oneness; expression of human
imagination and creativity, realization of the unity of knowing with
possibilities unfolding, and expression of choice and responsibility.
We have deliberately used the term general theory of nursing to
characterize our work. The concept of a general theory is particularly
useful in the context of levels of theory. Other authors have addressed
what they see as three levels of nursing theory: general or grand,
mid-range, and practice (Walker & Avant, 1988; Fawcett, 1989; Chinn
& Jacobs, 1987: Nursing Development Conference Group, 1979). What we
intend by the use of the term general theory is similar to "conceptual
framework," "conceptual model," or "paradigm." That is, a general theory
is a framework for understanding any and all instances of nursing, and
may be used to describe or to project any given situation of nursing.
It is a system of values ordered specifically to reflect a philosophy of
nursing to guide knowledge generation and to inform practice.
The statement of focus of any general nursing theory offers an
explicit expression of the social need that calls for and justifies the
professional service of nursing. In addition, the statement of focus
expresses the domain of a discipline as well as the intent of the
profession, and thus directs the development of the requisite nursing
knowledge. Activity to develop and use nursing knowledge has its ethical
ground in the idea of the covenantal relationship as expressed in the
specific focus of the profession. Fundamental values inherent in the
discipline and profession of nursing derive from an understanding of the
focus of nursing.
The conception of nursing that we have used in this book views nursing
science as a form of human science. Nursing as caring focuses on the
knowledge needed to understand the fullness of what it means to be human
and on the methods to verify this knowledge. For this reason, we have
not accepted the traditional notion of theory which relies on the
"received" view of science, and depends on measurement as the ultimate
tool for legitimate knowledge development. The human science of nursing
requires the use of all ways of knowing.
Carper's (1978) fundamental patterns of knowing in nursing are useful
conceptual tools for expanding our view of nursing science as human
science here. These patterns provide an organizing framework for asking
epistemological questions of caring in nursing. To experience knowing
the whole of a nursing situation with caring as the central focus, each
of these patterns comes into play. Personal knowing focuses on knowing
and encountering self and other intuitively, the empirical pathway
addresses the sense, ethical knowing focuses on moral knowing of what
"ought to be" in nursing situations, and aesthetic knowing involves the
appreciating and creating that integrates all patterns of knowing
in relation to a particular situation. Through the richness of the
knowledge gleaned, the nurse as artist creates the caring moment (Boykin
& Schoenhofer, 1990).
Nursing, as we have come to understand our discipline, is not a
normative science that stands outside a situation to evaluate current
observations against empirically derived and tested normative standards.
Nursing as a human science takes its value from the knowledge created
within the shared lived experience of the unique nursing situation.
Although empirical facts and norms do play a role in nursing knowledge,
we must remember that that role is not one of unmediated application.
Knowledge of nursing comes from within the situation. The nurse reaches
out into a body of normative information, transforming that information
as understanding is created from within the situation. The same can
be said for personal and ethical knowing. Each serves as a pathway for
transforming knowledge in the creation of aesthetic knowing within
the nursing situation. The view we have taken unifies previously
dichotomized notions of nursing as science and nursing as art and
requires a new understanding of science.
Nursing as caring reflects an appreciation of persons in the fullness
of per-sonhood within the context of the nursing situation. This view
transcends perspectives adopted in an earlier period of nursing science
philosophy. Examples of the earlier view include the notions of basic
versus applied science, and metaphysics versus theory. The idea of a
basic science of nursing disconnects nursing from its very ground of
ethical value. Without a grounding in praxis, the content and activity
of nursing science becomes amoral and meaningless. Similarly, this view
transcends an earlier view of nursing theory that treated the unitary
phenomenon of nursing as being composed of concepts that could be
studied independently or as "independent and dependent variables."
Nursing as caring resists fragmentation of the unitary phenomenon of
our discipline. In subsequent chapters, we will more fully explore
implications of this view of nursing as a human science discipline and
profession.
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