In Chapter 2, we will present the general theory of Nursing as Caring.
Here, the unique focus of nursing is posited as nurturing persons living
caring and growing in caring. While we will discuss the meaning of that
statement of focus in general terms, we will also describe specific
concepts inherent in this focus in the context of the general theory.
If you recall, in Chapter 1 we discussed the several major assumptions
that ground the theory of Nursing as Caring:
* Persons are caring by virtue of their humanness
* Persons are whole or complete in the moment
* Persons live caring, moment to 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 profession
In this and succeeding chapters, we will develop the nursing
implications of these assumptions.
All persons are caring. This is the fundamental view that grounds
the focus of nursing as a discipline and a profession. The unique
perspective offered by the theory of Nursing as Caring builds on that
view by recognizing personhood as a process of living grounded in
caring. This is meant to imply that the fullness of being human is
expressed as one lives caring uniquely day to day. The process of
living grounded in caring is enhanced through participation in nurturing
relationships with caring others, particularly in nursing relationships.
Within the theoretical perspective given herein, a further major
assumption appears: persons are viewed as already complete and
continuously growing in completeness, fully caring and unfolding caring
possibilities moment-to-moment. Such a view assumes that caring is being
lived by each of us, moment to moment. Expressions of self as caring
person are complete in the moment as caring possibilities unfold; thus,
notwithstanding other life contingencies, one continues to grow in
caring competency, in fully expressing self as caring person. To say
that one is fully caring in the moment also involves a recognition of
the uniqueness of person with each moment presenting new possibilities
to know self as caring person. The notion of "in the moment" reflects
the
idea that competency in knowing self as caring and as living caring
grows throughout life. Being complete in the moment also signifies
something more: there is no insufficiency, no brokenness, or absence
of something. As a result, nursing activities are not directed toward
healing in the sense of making whole; from our perspective, wholeness is
present and unfolding. There is no lack, failure, or inadequacy which is
to be corrected through nursing--persons are whole, complete, and caring.
The theory of Nursing as Caring, then, is based on an understanding that
the focus of nursing, both as a discipline and as a profession, involves
the nurturing of persons living caring and growing in caring. In this
statement of focus, we recognize the unique human need to which nursing
is the response as a desire to be recognized as caring person and to be
supported in caring.
This focus also requires that the nurse know the person seeking
nursing as caring person and that the nursing action be directed toward
nurturing the nursed in their living caring and growing in caring. We
will briefly discuss this theory in general terms here and more fully
illuminate it in subsequent chapters on nursing practice (Chapter 4),
education (Chapter 5), and scholarship (Chapter 6). We will address
administration of nursing services and of nursing education programs in
Chapters 4 and 5, respectively.
Nurturing persons living caring and growing in caring at first glance
appears broad and abstract. In some ways, the focus is broad in that it
applies to nursing situations in a wide variety of practical settings.
On the other hand, it takes on specific and practical meaning in the
context of individual nursing situations as the nurse attempts to know
the nursed as caring person and focuses on nurturing that person as he
or she lives and grows in caring.
When approaching a situation from this perspective, we understand each
person as fundamentally caring, living caring in his or her everyday
life. Forms of expressing one's unique ways of living caring are limited
only by the imagination. Recognizing unique personal ways of living
caring also requires an ethical commitment and knowledge of caring. In
our everyday lives, failures to express caring are readily recognized.
The ability to articulate instances of noncaring does not seem to
take any particular skill. When nursing is called for, however, it
is necessary that nurses have the commitment, knowledge, and skill to
discover the individual unique caring person to be nursed. For example,
the nurse may encounter one who may be described as despairing. Relating
to that person as helpless recalls Gadow's (1984) characterization of
the philanthropic paradigm which assumes "sufficiency and independence
on one side and needy dependence on the other" (p. 68). The relationship
grounded in nursing as caring would enable the nurse to connect with the
hope that underlies an expression of despair or hopelessness. Personal
expressions such as despair, or fear, or anger, for example, are neither
ignored nor discounted. Rather, they are understood as the caring value
which is in some way present. An honest expression of fear or anger, for
example, is also an expression of vulnerability, which expresses
courage and humility. We reiterate that our approach is grounded in the
fundamental assumption that all persons are caring and the commitment
which arises from this basic value position.
It is this understanding of person as caring that directs professional
nursing decision making and action from the point of view of our Nursing
as Caring theory. The nurse enters into the world of the other person
with the intention of knowing the other as caring person. It is in
knowing the other in their "living caring and growing in caring" that
calls for nursing are heard. Of equal importance is our coming to
know how the other is living caring in the situation and expressing
aspirations for growing in caring. The call for nursing is a call for
acknowledgement and affirmation of the person living caring in specific
ways in this immediate situation. The call for nursing says "know me as
caring person now and affirm me." The call for nursing evokes specific
caring responses to sustain and enhance the other as they live caring
and grow in caring in the situation of concern. This caring nurturance
is what we call the nursing response.
NURSING SITUATION
The nursing situation is a key concept in the theory of Nursing
as Caring. Thus, we understand nursing situation as a shared lived
experience in which the caring between nurse and nursed enhances
personhood. The nursing situation is the locus of all that is known and
done in nursing. It is in this context that nursing lives. The content
and structure of nursing knowledge are known through the study of
the nursing situation. The content of nursing knowledge is generated,
developed, conserved, and known through the lived experience of the
nursing situation. Nursing situation as a construct is constituted
in the mind of the nurse when the nurse conceptualizes or prepares to
conceptualize a call for nursing. In other words, when a nurse
engages in any situation from a nursing focus, a nursing situation is
constituted.
In the Scandinavian countries, for instance, all the helping disciplines
are called caring sciences. Professions such as medicine, social work,
clinical psychology, and pastoral counseling have a caring function;
however, caring per se is not their focus. Rather, the focus of each
of these professions addresses particular forms of caring or caring in
particular ranges of life situations. In nursing situations, the nurse
focuses on nurturing person as they live and grow in caring. While
caring is not unique to nursing, it is uniquely expressed in nursing.
The uniqueness of caring in nursing lies in the intention expressed
by the statement of focus. As an expression of nursing, caring is the
intentional and authentic presence of the nurse with another who is
recognized as person living caring and growing in caring. Here, the
nurse endeavors to come to know the other as caring person and seeks
to understand how that person might be supported, sustained, and
strengthened in kis or her unique process of living caring and growing
in caring. Again, each person in interaction in the nursing situation is
known as caring. Each person grows in caring through interconnectedness
with other.
Calls for nursing are calls for nurturance through personal expressions
of caring, and originate within persons who are living caring in their
lives and hold dreams and aspirations of growing in caring. Again,
the nurse responds to the call of the caring person, not to some
determination of an absence of caring. The contributions of each person
in the nursing situation are also directed toward a common purpose, the
nurturance of the person in living and growing in caring.
In responding to the nursing call, the nurse brings an expert (expert
in the sense of deliberately developed) knowledge of what it means to be
human, to be caring, as a fully developed commitment to recognizing and
nurturing caring in all situations. The nurse enters the other's world
in order to know the person as caring. The nurse comes to know how
caring is being lived in the moment, discovering unfolding possibilities
for growing in caring. This knowing clarifies the nurse's understanding
of the call and guides the nursing response. In this context, the
general knowledge the nurse brings to the situation is transformed
through an understanding of the uniqueness of that particular situation.
Every nursing situation is a lived experience involving at least two
unique persons. Therefore, each nursing situation differs from any
other. The reciprocal nature of the lived experience of the nursing
situation requires a personal investment of both caring persons. The
initial focus is on knowing persons as caring, both nurse and nursed.
The process for knowing self and other as caring involves a constant and
mutual unfolding. In order to know the other, the nurse must be willing
to risk entering the other's world. For his or her part, other person
must be willing to allow the nurse to enter his or her world this to
happen, the acceptance of trust and strength of courage needed, person
in the nursing situation can be awe-inspiring.
It is through the openness and willingness in the nursing situation that
presence with other occurs. Presence develops as the nurse is willing to
risk entering the world of the other and as the other invites the nurse
into a special, intimate space. The encountering of the nurse and the
nursed gives rise to a phenomenon we call caring between, within which
personhood is nurtured. The nurse as caring person is fully present
and gives the other time and space to grow. Through presence and
intentionality, the nurse is able to know the other in his or her
living and growing in caring. This personal knowing enables the nurse
to respond to the unique call for nurturing personhood. Of course,
responses to nursing calls are as varied as the calls themselves. All
truly nursing responses are expressions of caring and are directed
toward nurturing persons as they live and grow in the caring in the
situation.
In the situation, the nurse draws on personal, empirical, and ethical
knowing to bring to life the artistry of nursing. When the nurse, as
artist, creates a unique approach to care based on the dreams and goals
of the one cared for, the moment comes alive with possibilities. Through
the aesthetic, the nurse is free to know and express the beauty of the
caring moment (Boykin & Schoenhofer, 1991). This full engagement within
the nursing situation allows the nurse to truly experience nursing as
caring, and to share that experience with the one nursed.
In Chapter 1, we noted that each profession arose from some everyday
service given by one person or another. Nursing has long been associated
with the idea of mothering, when mothering is understood as nurturing
the personhood of another. The ideal mother (and father) recognizes
the child as caring person, perfect in the moment and unfolding
possibilities for becoming. The parent acknowledges and affirms the
child as caring person and provides the caring environment that nurtures
the child in living and growing in caring. The origins of nursing may
well be found in the intimacy of parental caring. The roles of both
parent and nurse permit and at times even expect that one be involved in
the intimacy of the daily life of another. The parent is present in all
situations to care for the child. Ideally, parents know the child as
eminently worthwhile and caring, despite all the limitations and human
frailties. As we recognized in Chapter 1, professions arise from the
special needs of everyday situations, and nursing has perhaps emerged
in relation to a type of caring that is synonymous with parenthood
and friendship. The professional nurse, schooled in the discipline
of nursing, brings expert knowledge of human caring to the nursing
situation.
In the early years of nursing model development, nursing scholars
endeavored to articulate their discipline using the perspective of
another discipline, for example, medicine, sociology, or psychology.
One example of this endeavor is the Roy Adaptation Model, in which
scientific assumptions reflect von Bertalanffy's general systems theory
and Helson's adaptation level theory (Roy and Andrews, 1991, p. 5).
Parson's theory of Social System Analysis is reflected in Johnson's
Behavioral System Model for Nursing and Orem's Self-Care Deficit Theory
of Nursing (Meleis, 1985). A second trend involved declaring that the
uniqueness of nursing was in the way in which it integrated and applied
concepts from other disciplines. The emphasis in the 1960s on nursing
model development came as an effort to articulate and structure the
substance of nursing knowledge. This work was needed to enhance nursing
education, previously based on rules of practice, and to provide
a foundation for an emerging interest in nursing research. Nursing
scholars engaged in model development as an expression of their
commitment to the advancement of nursing as a discipline and profession,
and we applaud their contributions. It is our view, however, that these
early models, grounded in other disciplines, do not directly address the
essence of nursing. The development of Nursing as Caring has benefited
from these earlier efforts as well as from the work of more recent
scholarship that posits caring as the central construct and essence
(Leininger, 1988), and the moral ideal of Nursing (Watson, 1985).
The perspective of nursing presented here is notably different from most
conceptual models and general theories in the field. The most radical
difference becomes apparent in the form of the call for nursing. Most
extant nursing theories, modeled after medicine and other professional
fields, present the formal occasion for nursing as problem, need, or
deficit (e.g., Self-Care)
Deficit Theory [Orem, 1985], Adaptation Nursing [Roy and Andrews,
1991], Behavioral System Model [Johnson, 1980], and [Neuman, 1989.]
Such theories then explain how nursing acts to right the wrong, meet the
need, or eliminate or ameliorate the deficit.
The theory of Nursing as Caring proceeds from a frame of reference
based on interconnectedness and collegiality rather than on esoteric
knowledge, technical expertise, and disempowering hierarchies. In
contrast, our emerging theory of nursing is based on an egalitarian
model of helping that bears witness to and celebrates the human person
in the fullness of his or her being, rather than on some less-than-whole
condition of being.
REFERENCES
Boykin, A., & Schoenhofer, S. (1991). Story as link between nursing practice, ontology, epistemology. Image, 23, 245-248.
Gadow, S. (1984). Touch and technology: Two paradigms of patient care. Journal of Religion and Health, 23, 63-69.
Johnson, D.E. (1980). The behavioral system model of nursing. In J. Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd ed.). New York: Appleton-Century-Crofts.
Leininger, M.M. (1988). Leininger's theory of nursing: Cultural care diversity and universality. Nursing Science Quarterly, 1, 152-160.
Meleis, A. (1985). Theoretical nursing: Development & progress. Philadelphia: J.B. Lippencott.
Neuman, B. (1989). The Neumans systems model. Norwalk, CT: Appleton & Lange. Orem, D.E. (1985). Nursing: Concepts of practice (3rd ed.). New York: McGraw Hill.
Roy, C., & Andrews, H. (1991). The Roy Adaptation Model: The definitive statement. Norwalk, CT: Appleton & Lange.
Watson, J. (1985). Nursing: Human science and human care. A theory of nursing. Norwalk, CT: Appleton-Century-Crofts.
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