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Title: Nursing as Caring - A Model for Transforming Practice
Author: Boykin, Anne, Schoenhofer, Savina O.
Language: English
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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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  and social policy: Philosophical and ethical dimensions. Journal of Advanced
  Nursing, 8 (2), 147-151.
  Tillich, P. (1952). The courage to be. New Haven: Yale University Press.
  Trigg, R. (1973). Reason and commitment. London: Cambridge University Press.
  Walker, L., & Avant, K. (1988). Strategies for theory construction in nursing. Norwalk, CT:
  Appleton & Lange.
  Watson, J. (1988; 1985). Nursing: Human science and human care, a theory of nursing. Nor-
  walk, CT: Appleton-Century-Crofts.
  White, C.M. (1984). A critique of the ANA Social Policy Statement ... population and
  environment focused nursing. Nursing Outlook, 32 (6), 328-331.



[Illustration: Button]


CHAPTER II. -- NURSING AS CARING

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.



[Illustration: Button]


CHAPTER III -- NURSING SITUATION AS THE LOCUS OF NURSING

The concept of nursing situation is central to every aspect of the
theory of Nursing as Caring. We have claimed that all nursing knowledge
resides within the nursing situation (Boykin & Schoenhofer, 1991). The
nursing situation is both the repository of nursing knowledge and the
context for knowing nursing. The nursing situation is known as shared
lived experience in which the caring between the nurse and the one
nursed enhances personhood.

It is to the nursing situation that the nurse brings self as caring
person. It is within the nursing situation that the nurse comes to know
the other as caring person, expressing unique ways of living and growing
in caring. And it is in the nursing situation that the nurse attends to
calls for caring, creating caring responses that nurture personhood. It
is within the nursing situation that the nurse comes to know nursing, in
the fullness of aesthetic knowing.

The nursing situation comes into being when the nurse actualizes a
personal and professional commitment to the belief that all persons
are caring. It should be recognized that a nurse can engage in many
activities in an occupational role that are not necessarily expressions
of nursing. When a nurse practices nursing thoughtfully, that nurse
is guided by his or her conception of nursing. The concept of nursing
formalized in the Nursing as Caring theory is at the very heart of
nursing, extending back into the unrecorded beginnings of nursing
and forward into the future. Acknowledgement of caring as the core
of nursing implies that any nurse practicing nursing thoughtfully is
creating and living nursing situations because, whether explicit or
tacit, the caring intent of nursing is present.

Remember that the nursing situation is a construct held by the nurse,
any interpersonal experience contains the potential to become a nursing
situation. In the formal sense of professional nursing, the nursing
situation develops when one person presents self in the role of offering
the professional service of nursing and the other presents self in the
role of seeking, wanting, or accepting nursing service.

The nurse intentionally enters the situation for the purpose of coming
to know the other as caring person. The nurse is also allowing self
to be known as caring person. Authentic presence, like most human
capacities, is inherent and can be more fully developed through
intention and deliberate effort. Authentic presence may be understood
simply as one's intentionally being there with another in the fullness
of one's personhood. Caring communicated through authentic presence
is the initiating and sustaining medium of nursing within the nursing
situation.

The nurse, with developed authentic presence and open to knowing the
other as caring, begins to understand the other's call for nursing.
A call for nursing is a call for specific forms of caring that
acknowledge, affirm, and sustain the other as they strive to live caring
uniquely. We must remember as well that calls for nursing originate
within the unique relationship of the nursing situation. As the
situation ensues, the call for nursing clarifies. The nurse comes to
know the one nursed more and more deeply and to understand more fully
the unique meaning of the person's caring ways and aspirations for
growing in caring. It is in this understanding that the call for nursing
is known as a specific situated expression of caring and a call for
explicit caring response.

The nursing response of caring is also uniquely lived within each
nursing situation. In the nursing situation, the call of the nursed is a
personal "reaching out" to a hoped-for other. The nursed calls forth
the nurse's personal caring response. While the range and scope of human
caring expression can and must be studied, the caring response called
forth in each nursing situation is created for that moment. The nurse
responds to each call for nursing in a way that uniquely represents the
fullness (wholeness) of the nurse. How I might respond to such a call
would and should reflect my unique living of caring as person and
nurse. Each response to a particular nursing situation would be slightly
different and would portray the beauty of the nurse as person.

The nursing situation is a shared lived experience. The nurse joins in
the life process of the person nursed and brings his or her life process
to the relationship as well. In the nursing situation, there is caring
between the participants. Further, the experience of the caring within
the nursing situation enhances personhood, the process of living
grounded in caring. Each of these components of the construct of
the nursing situation raises questions for immediate and continuing
discussion.

How can an unconscious patient be a participant in a nursing situation?
Can "postmortem care" be considered nursing? How can the nurse know that
the other is truly open to nursing--can the nurse impose self into the
world of the other? What about an unrepentant child rapist or a person
responsible for genocide, can we say that person is caring, and if not,
can we nurse them? Does the nurse have to like the person being nursed?
Does the nurse seek enhancement of personhood in the nursing situation?
If so, might the goals of the nurse be imposed on the one nursed? If the
nurse gains from the nursing situation, isn't that unprofessional?

In part, these legitimate questions raise larger issues about the
uniqueness and scope of nursing as a discipline and professional service
in society. Certainly the study of these questions adds clarity to the
purpose of nursing actions. To nurse, situations in a general sense
are transcended and transformed When they are conceptualized as nursing
situations. From the perspective of the Nursing as Caring theory, the
study of these questions would require that the nurse transcend social
or other situational contexts and live out a commitment to nurture the
person in the nursing situation as they live and grow in caring.

Persons with altered levels of consciousness, measured on normative
scales developed for medical science purposes, can and do participate
in nursing situations. Nurses committed to knowing the unconscious as
caring person can and do describe their ways of expressing caring and
aspirations for growing in caring. Nurses speak of the post-anesthesia
patient as living hope in their struggle to emerge from the deadening
effects of the anesthesia; as living honestly in fretful, fearful
thrashing. Nurses help these persons sustain hope and extend honesty
through their care. The profoundly mentally disabled child lives
humility moment-to-moment and calls forth caring responses to validate
and nurture that beautiful humility. Nurses speak of caring for their
deceased patients as nursing those who have gone and are still in some
way present. The nurse, connected in oneness with the one known
and nursed, holds hope for the other as the other's expression of
hopefulness lives on in the consciousness of the nurse. Thus, a sense
of connectedness does not dissipate when physical presence ends, but
remains an active part of the nurse's experience.

Nursing another is a service of caring, communicated through authentic
presence. Nursing another means living out a commitment to knowing the
other as caring person and responding to the caring other as someone of
value (Boykin & Schoenhofer, 1990, 1991). In its fullest sense, nursing
cannot be rendered impersonally, but must be offered in a spirit of
being connected in oneness. "To care for" seems to require that the
caregiver see oneself as caring person reflected in the other (Watson,
1987). The theoretical perspective of Nursing as Caring is grounded in
the belief that caring is the human mode of being (Roach, 1984). When
a person is judged by social standards to be deviant and even
evil, however, it is difficult to summon caring. This points to the
contribution nursing is called upon to make in society. When we speak
of nursing's contribution here, we are invoking earlier discussions of
discipline and profession. Each discipline and profession illuminates a
special aspect of person--in effect, what it means to be human. The light
that nursing shines on the world of person is knowledge of person as
caring, so that the particular contribution of nursing is to illuminate
the person as caring, living caring uniquely in situation and growing in
caring. In nursing, practiced within the context of Nursing as Caring,
the person is taken at face value as caring and never needs to prove
him or herself as caring. The nurse, practicing within the context of
Nursing as Caring, is skilled at recognizing and affirming caring in
self and others. Being caring, that is, living one's commitment to this
value "important-in-self" (Roach, 1984), fuels the nurse's growing in
caring and enables the nurse I turn to nurture others in their living
and growing in caring. The values and assumptions of nursing as caring
can assist the nurse to engage fully in nursing situations with persons
in whom caring is difficult to discover.

Nursing knowledge is discovered and tested in the ongoing nursing
situations. Once experienced, nursing situations can be made
available for living anew, with new discovery and testing. Aesthetic
representation of nursing situations brings the lived experience into
the realm of new experience. Thus, the knowledge of nursing can be made
available for further study. Re-presentation of nursing situations
can occur through the medium of nursing stories, poetry, painting,
sculpture, and other art forms (Schoenhofer, 1989). Aesthetic
re-presentation conserves the epistemic integrity of nursing while
permitting full appreciation of the singularity of any one nursing
situation (Boykin & Schoenhofer, 1991). Here, then, is one nurse's story
of a shared lived experience in which the caring between nurse and the
one nursed enhanced personhood. This story is offered as an example
of nursing situation, re-presented as an open text, available for
continuing participation by all who wish to enter into this shared lived
experience of nursing. In fact, we invite the reader to enter into this
nursing situation, which may then be used in classroom or conference
settings to stimulate general or specific inquiry and dialogue.


CONNECTIONS

  One night as I listened to the change of shift report, I remember the
  strange feeling in the pit of my stomach when the evening nurse reviewed
  the lab tests on Tracy P Tall, strawberry-blonde and freckle-faced,
  Tracy was struggling with the everyday problems of adolescence and
  fighting a losing battle against leukemia. Tracy rarely had visitors.
  As I talked with Tracy this night I felt resentment from her toward her
  mother, and I experienced a sense of urgency that her mother be with
  her. With Tracy's permission I called her mother and told her that Tracy
  needed her that night. I learned that she was a single mother with
  two other small children, and that she lived several hours from the
  hospital. When she arrived at the hospital, distance and silence
  prevailed. With encouragement, the mother sat close to Tracy and I sat
  on the other side, stroking Tracy's arm. I left the room to make rounds
  and upon return found Mrs. P. still sitting on the edge of the bed
  fighting to stay awake. I gently asked Tracy if we could lie on the bed
  with her. She nodded. The three of us lay there for a period of time and
  I then left the room. Later, when I returned, I found Tracy wrapped
  in her mothers arms. Her mothers eyes met mine as she whispered "she's
  gone." And then, "please don't take her yet." I left the room and closed
  the door quietly behind me. It was just after 6 o'clock when I slipped
  back into the room just as the early morning light was coming through
  the window. "Mrs. P," I reached out and touched her arm. She raised her
  tear-streaked face to look at me. "It's time," I said and waited. When
  she was ready, I helped her off the bed and held her in my arms for
  a few moments. We cried together. "Thank you, nurse," she said as she
  looked into my eyes and pressed my hand between hers. Then she turned
  and walked away. The tears continued down my cheeks as I followed her to
  the door and watched her disappear down the hall.

                                                   Gayle Maxwell (1990)


This nursing situation is replete with possibilities for nurses, and
others, to understand nursing as nurturing persons living caring and
growing in caring. A dialogue ensues on the nursing situation that
allows participants an opportunity to experience both resonance and
uniqueness as personal and shared understandings emerge. As the reader
enters into the text, the nursing situation is experienced anew,
now within the presence of two nurses, not one. Though intentionally
entering the situation, the second nurse experiences d affirms being
connected in oneness with both nurse and nursed as caring lived in the
moment.

Gayle entered into Tracy's world that night open to hearing a special
call. Gayle's openness was partly a reflection of her use of the
empirical pathway of knowing, the data given in report, the comparison
of empirical observations against biological, psychological,
developmental, and social norms. Before discussing our understanding of
Gayle's response from the theoretical per-perspective represented,
it might be helpful to compare how the call for nursing may have been
interpreted if approached, for example, from a psychological framework.
If the nurse responded from a psychological framework, the problem
identified would perhaps be conceptualized as denial on the part of
Tracy's mother. It could be assumed that Tracy's mother was avoiding the
reality of the impending death of her daughter. Here, the nursing goal
would be assist the mother in dealing with her denial by facilitating
grieving. Denial is only one psychological concept that could be applied
in this situation; avoidance, anxiety, and loss are others. When nursing
care is based on a psychological framework, however, the central theme
of care is likely to be deemphasized in favor of a problem-oriented
approach. The perspective offered by a normative discipline requires
a reliance on empirical knowing. Using only the empirical pathway of
knowing, the richness of nursing is lost.

Gayle's personal knowing, her intuition, however, was the pathway
that illuminated the appreciation of this situation and prompted her
acknowledgement of a call. She heard Tracy's call for intimacy, comfort,
and protection of her mother's presence as she (Tracy) summoned courage
and hope for her journey. Gayle intuitively knew that the specific
caring being called forth was the caring of a mother. Gayle's caring
response also took the form of the courageous acknowledgement of a call
for nursing that would be difficult to sub-stantiate empirically. Beyond
telephoning Tracy's mother, Gayle continued her nursing effort to answer
Tracy's call for the presence of a mother as she supported Mrs. P. living
her interconnectedness, in being with Tracy. Gayle heard Mrs. P.'s calls
for knowing, knowing what to do and knowing that it would be right to
do it, for the courage to be with her daughter in this new difficult
passage. Her response of showing the way reflects hope and humility. The
caring between the nurse and the ones nursed enhanced the personhood of
all three, as each grew in caring ways. It is possible that the caring
between the original participants in the nursing situation and those of
us who are participating through engagement with the text continues to
enhance personhood.


REFERENCES

  Boykin, A., & Schoenhofer, S. (1991). Story as link between nursing practice, ontology, epistemology. Image, 23, 245-248.
  Boykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis of extant theory. Nursing Science Quarterly, 4, 149-155.
  Maxwell, G. (1990). Connections. Nightingale Songs, 1 (1). P.O. Box 057563, West Palm Beach, FL 33405.
  Paterson, J., & Zderad, L. (1988). Humanistic nursing. New York: National League for Nursing Press.
  Roach, S. (1984). Caring: The human mode of being, implications for nursing. Toronto: Faculty of Nursing, University of Toronto. (Perspectives in Caring Monograph 1).
  Schoenhofer, S. (1989). Love, beauty and truth: Fundamental nursing values. Journal of Nursing Education, 28 (8), 382-384.
  Watson, J. (1987). Nursing on the caring edge; Metaphorical vignettes. Advances in Nursing Science, 10, 10-18.



[Illustration: Button]


CHAPTER IV. -- IMPLICATIONS FOR PRACTICE AND NURSING SERVICE ADMINISTRATION

Foundations for practice of the Nursing as Caring theory rest on
the nurse coming to know self as caring person in ever deepening and
broadening dimensions. While all nurses may have (or at least, may
have had) a sense of self as caring person, practicing within this
theoretical framework requires a deliberate commitment to developing
this knowledge. In many settings where nurses find themselves
practicing, there is little in the environment to support a commitment
to ongoing development of a sense of self as caring person. In fact,
many practice environments seem to support knowing self only as
instrument, self as technology. When one perceives of one's "nursing
self" as a depersonalized, disembodied tool, nursing tends to lose
its flavor and the devoted commitment to nursing burns out. So how to
sustain and actualize this fundamental commitment must be a point of
serious study for the nurse who desires to practice nursing as caring.

Mayeroff's (1971) caring ingredients are useful tools to assist the
nurse in developing an ever-present awareness of self as caring person.
Taking note of personal patterns of expressing hope, honesty, courage,
and the other ingredients is a good starting place. Understanding the
meaning of living caring in one's own life is an important base for
practicing nursing as caring. In reflecting on a particular lived
experience of caring, the nurse can seek to understand the ways in which
caring contributed freedom within the situation--freedom to be, freedom
to choose, and freedom to unfold.

Because nursing is a way of living caring in the world, the nurse can
turn his or her attention to personal patterns of nursing as expressions
of caring. As self understanding as caring person accrues, the nurse
sometimes realizes that such self-awareness was there all along--it
was only waiting to be discovered. Because many nurses were trained to
overlook their caring ways instead of attending to them, nurses may now
need something similar to, or indeed "sensitivity training" itself,
to rediscover and reown the possibilities of self as caring person,
possibilities specific to nursing as a profession and a discipline. This
redirection of focus away from caring may have been related to several
historical social movements. First, of course, is the move toward
science, which for nursing meant that for a period of several decades
nursing education seemed to reject, either partially or totally, the art
of nursing in order to discover a scientific base for practice. Another
related process, the technology movement, led nurses to understand care
as a series of sequential actions designed to accomplish a specifiable
end. In this context, nursing care became synonymous with managing
available technologies. Third, there existed in the history of nursing
education an era(s) in which nurses were taught to treat symptoms
patients expressed, rather than to care for the person. Fourth,
maintaining a professional distance was a hallmark of professionalism.
Now, and rightly so, the tide has turned. A reawakening of knowing self
as caring person becomes paramount so that the profession of nursing
returns caring to the immediacy of the nursing situation.

With personal awareness and reflection, developed knowledge of caring
also arrives through empirical, ethical, and aesthetic modes of knowing.
There is a growing body of literature in nursing that both attests
to that fact and to the process of how nurses communicate caring in
practice (e.g., Riemen, I 986a, 1986b; Knowlden, 1986; Swanson-Kauffman,
1986a, 1986b; Swanson, 1990; Kahn and Steeves, 1988). Given the various
perspectives offered by the authors just mentioned, the individual nurse
can enhance his or her ethical self-development as a caring person by
cultivating the practice of weighing the various meanings of caring
now extant in actual practice situations and then by making choices to
express caring creatively. In pursuit of this end, aesthetic knowing
often subsumes and transcends other forms of knowing and thus may
offer the richest mode of knowing caring. Appreciating structure,
form, harmony, and complementarity across a range of situated caring
expressions enhances knowing self and other as caring persons.

Knowing self as caring enhances knowing of the other as caring. Knowing
other as caring contributes to our discovery of caring self. Without
knowing the other as caring person, there can be no true nursing. Living
a commitment to nursing as caring can be a tremendous challenge when
nurses are asked to care for someone who makes it difficult to care. In
effect, it is impossible to avoid the issue of "liking" or "disliking"
the patient. Is it possible to truly care for someone if the nurse
doesn't like him or her? In this light, another question arises: How can
1 enter the world of another who repulses me? Am I expected to pretend
that this person (the patient) has not treated others inhumanely (if
that is the case)? Must I ignore the reality of the other's hatefulness
toward me (if such exists)? These are questions that come from the human
heart. They express legitimate human issues that present themselves
regularly in nursing situations.

The commitment of the nurse practicing nursing as caring is to nurture
persons living caring and growing in caring. Again, this implies
that the nurse come to know the other as caring person in the moment.
"Difficult to care" situations are those that demonstrate the extent
of knowledge and commitment needed to nurse effectively. An everyday
understanding of the meaning of caring is obviously inadequate when the
nurse is presented with someone for whom it is difficult to care. In
these extreme (though not unusual) situations, a task-oriented, non
discipline-based concept of nursing may be adequate to assure the
completion of certain treatment and surveillance techniques. Still,
in our eyes that is an insufficient response--it certainly is not the
nursing we advocate. The theory, Nursing as Caring, calls upon the
nurse to reach deep within a well-developed knowledge base that has
been structured using all available patterns of knowing, grounded in the
obligations inherent in the commitment to know persons as caring. These
patterns of knowing may include intuition, scientifically quantifiable
data emerging from research, related knowledge from a variety of
disciplines, ethical beliefs, as well as many other types of knowing.
All knowledge held by the nurse which may be relevant to understanding
the situation at hand is drawn forward and integrated into practice
in particular nursing situations. Although the degree of challenge
presented from situation to situation varies, the commitment to know
self and other as caring persons is steadfast.

Caring expressed in nursing is personal, not abstract. The caring that
is nursing cannot be expressed as an impersonal generalized stance of
good will, but must be expressed knowledgeably. That is, the caring
that is nursing must be a lived experience of caring, communicated
intentionally, and in authentic presence through a person-with-person
interconnectedness, a sense of oneness with self and other. The nurse is
not expected to be super-human, superficial, or naïve. Rather, a genuine
openness to caring and a formed intention of knowing the other as caring
person are required. In this sense, and referring back to patients with
whom an expression of empathy is problematic; liking may be understood
as a less personally committed form of caring or loving. In other words,
liking is superficial and may not require the devotion needed to know
other as caring. When the nurse truly connects with the other, liking
the other becomes a moot issue.

Stories nurses tell about their nursing bring to light the sustenance
they find in the nursing situation. Lived experiences of practice,
recounted to crystallize the essential meaning of nursing, contain the
tangible seeds of awareness of self as caring person. However, the nurse
may not be fully aware of self as caring person until the nursing
story is articulated and shared. When the practicing nurse can begin
to describe practice as the personal expression of caring with and for
another, possibilities for living nursing as caring emerge.

Here is one nurse's response to the invitation to tell a story that
conveys the beauty of nursing. The authentic presence of the nurse in
the following nursing situation focuses on honesty as an expression of
self as caring person.


HONESTY

As Jason came through the door to RAC, a young black man lying
lifelessly on a stretcher of pale green linen, the surgeon came towards
me telling me not to tell Jason that his biopsy was positive.

I felt inner terror. A man, less than 18 years old, was going to come
close to the "truth" of living today. Yet the terror inside me was
really fueled by the becoming moral issue I was going to face soon.

Jason was surely going to ask of the results upon waking from
anesthesia. "They always do." Going to sleep unknowing demands
waking-to-know. "Honesty."

Honesty as a lived precept of caring requires that I, nurse, must always
and ever regard the person nursed from a position of love. I must enter
all nursing activity with the sole purpose of using truth, only and
ever, to promote the spiritual growth of the person nursed. In this
climate of openness to myself and to the other, we can begin to
experience freedom from fear.

Jason inevitably opened his eyes only seconds or minutes later--I was so
concerned with the surgeon's directive that I lost perception of time.
My choice? The surgeon's choice? Jason's choice?

All too soon, before I could decide "how" to act, Jason had arrived at
our moment of honesty versus dishonesty.

There were tears in Jason's eyes and as quickly as the endotrachial tube
was removed, words came from Jason's essence. "Why me, God?"

I was pre-empted. (That's what happens when I write the script of
nursing.)

Instead of dancing around "telling" Jason, I was now only able to
"be-with" Jason. To suffer with Jason, to come to compassionate knowing
of Jason's subjective reality. "I heard him," Jason choked and sobbed.

I just sat next to his stretcher and held his left hand with my right
hand. I softly stroked his shoulder. This intimate hand-in-hand gesture
only expressed a small part of the instant connectedness that we were
co-experiencing, each alone, each with the other, all at once.

I sat there for more than thirty minutes telling Jason repeatedly to
rest, trust God to help him, have strength, courage, and hope.

Having come together, Jason and I, through the darkness of anesthetized
sleep to the harsh reality of "wakefulness," we both move on with our
lives.

I asked the surgeon of Jason several times, but he couldn't remember
Jason.

I will never forget Jason. Jason brought me closer to understanding
honesty as caring (Little, 1992).


An explicit realization of nursing as a personal expression of caring
can fuel a commitment to growing in caring throughout life. A vivid,
articulated sense of self connects with an equally strong and explicit
sense of nursing, and a personal commitment to caring in and through
nursing is created. Research makes the unequivocal point that those who
seek our nursing service identify caring as the sine qua non of nursing
(Samaral), 1988; Winland-Brown & Schoenhofer, 1992). Entering these
covenantal relationships obligates us to mutually live and grow in
caring. What has also become apparent through our practice is that it
is increasingly difficult for nurses to conceptualize their service
as caring. Many nurses have lost faith in themselves as persons
contributing caring in health service delivery situations. Thus, the
raison d'être for the professional service career of nursing is lost,
and nurses become disheartened.

It is our experience, as illustrated in the previous story, Honesty,
that nurses can recapture the spirit of nursing, can rekindle hope
for themselves as persons caring through and in nursing. The reader
is invited to pause a moment and experience a sense of self as person
expressing caring in nursing. You are invited to enter a quiet,
contemplative inner space. Allow the attentions and distractions of the
moment to recede as you create quietude. Now, bring to life the most
beautiful nursing you have ever done. Recall that precious instance
that stands out for you as truly nursing. Savor the fullness of that
experience. Explore the meaning of this wonderful experience of nursing.

If possible, pause now and tell the story of your finest nursing
moment--aloud to another nurse, or in writing to the nurse you are today.
Share your story and invite other nurses to share theirs with you.

Now that the moment has been reborn and communicated, it is available as
a powerful resource for you. The essence of nursing which connects you
to all others in nursing is also to be found here. In that story resides
the central meaning of nursing, available now for your inspiration and
for your study.

For many nurses, the practice of nursing as caring will require changes
in the conceptualization of nursing and nursing practice structures.
Certain ideologies and cognitive frameworks that have gained prominence
in nursing in the recent past are not fully congruent with the values
expressed in the Nursing as Caring theory.

For example, the problem-solving process introduced into nursing by
Orlando (1961), known as the Nursing Process, comes from a worldview
that is incompatible with that which undergirds nursing as caring. In
the 1960s, nurses came to value Orlando's Nursing Process for its role
in helping them organize and put to use a growing body of scientific
nursing knowledge. Having borrowed the "problematizing" approach to
service delivery that was so successful in medical contexts, the Nursing
Process also fit with an emerging documentation system known as Problem
Oriented Medical Records, which again was adapted from medicine for
nursing use. During the late 1970s and through the 1980s, this impetus
was further developed in the Nursing Diagnosis movement.

What difficulties exist with the problem-solving process in nursing?
More than anything else, this process directs nurses to locate something
in the internal or external environment or character of the client that
is in need of correction. Gadow (1984) refers to this view as a paradigm
of philanthropy. In this demeaning paradigm, "touch is a gift from one
who is whole to one who is not" (p. 68). Within the context of Orlando's
Nursing Process, such problem solving requires that the nurse find
something that needs correction to legitimately offer appropriate care.
This focus on correction--and cure--distracts nurses from their primary
mission of caring and therefore practice results in objectification,
labeling, ritualism, and non-involvement. The context for nursing is
lost.

Further, Orlando's Process has resulted in nursing's knowledge base
being ever more deeply grounded in disciplines other than nursing.
An examination of a list of nursing diagnoses reveals that specific
knowledge from disciplines such as medicine, psychology, anthropology,
sociology, and epidemiology is what is required to solve the problems
to which the diagnoses refer. Rather than leading nurses toward the
development of the knowledge of nursing, Orlando's Nursing Process has
intensified the concept of nursing as a context-free integrator of other
disciplines.

The following story of a nursing situation demonstrates the freedom and
creativity that is possible when the nurse takes a focused, unfolding
view of the lived world of nursing. What occasioned this nursing
relationship was conceptualized in the larger system as providing care
for the caregiver, providing support in a family context. Here, home
nursing is seen as once again on the ascendancy as nurses discover
what is increasingly missing in institutional bureaucratic settings--the
opportunity to nurse.


CONNECTEDNESS

I was with J. tonight, and for the first time I enjoyed "authentic
presence" with her. I am not so sure it was because I was less fatigued
and more receptive to "what is" in her home, but because J. was clearly
"different" tonight. She greeted me with her usual rush of activity and
then startled me by asking me to "be with me, please," when she gave her
son an injection and changed the injection site on his central venous
catheter line. I had met her son before, but had never been invited to
his room or the upstairs quarters. We spent a long time in A's room
with J. and A. talking, sharing thoughts and feelings about (sister) K.,
frustrations of J. trying to do it all and still find a little peaceful
time for herself, angry outbursts and feelings of shame and sadness, and
J's desire to go to Mass on Sunday without feelings of extreme anger and
despair because K. cries when J. leaves the house, and ending with J's
stated determination to do the impossible task of being all things to
all people at all times. The dialogue was really between mother and son,
with questions directed toward me but immediately answered by J. and A.
The conversation was sparkling with humor and piercing with honesty, and
created in mind's eye a rich, colorful mosaic of years of love, beauty,
and truth. Tonight I wish I were an artist so I could capture this
vision on canvas.

1. asked me to stay with A. while she did a small chore in the kitchen,
and I settled in a side chair for whatever might present itself. The
I.V. pole in the corner of the room caught my attention and A. offered
the name of the drug and its purpose. I honestly did not know that
particular drug, and had nothing to offer, so I just nodded my head.
A. looked at me, cleared his throat, and proceeded to tell me about a
problem he is encountering. I interrupted him and told him that I know
nothing about him other than his name and he is J's son, and that J.
has not shared anything about him privately with me. He smiled, and then
with his head bowed and eyes peering at me, told me that he has
AIDS, worries about the stigma, and dreads the stance most health
professionals assume when he encounters them as they interpret the name
of his disease process. I sat very still and nodded my head. I wanted to
acknowledge his pain and show acceptance of him and what appeared to be
his need to connect with me. Together we reflected on the wonderfulness
of the human spirit, the concept of personhood, and holistic beings with
thoughts, feelings, wants, and needs. When A. was ready we ventured down
the stairs and found J. sitting quietly in a rocking chair. It seemed
she had finished her "task," and I wondered how long she had been
sitting alone. I sensed that she had invited me into her private pain,
and courageously shared another part of her life with me. I also knew
intuitively that she did not want to talk about it.

J. had prepared the piano, and all of them asked me to play for them and
expressed disappointment that I did not play the piano during my visit
last week. So I played gentle, reflective songs interspersed with light
melodic phrases. Requests were offered by each member of the family,
and within minutes J. was sitting next to me on the piano bench, singing
loudly and punctuating words with feelings and strength and lending
incredible meaning to lyrics. "Old Man River," deep, low, rumbling of
the piano and purposefully driving tempo was responded to in kind with
J. stamping her food with each beat and pounding her knee with each
word as she emphatically sang "He just keeps rolling along, he keeps on
rolling along." It seemed to be cathartic for her as expressions seemed
to come from the center of her being. We applauded ourselves when we
finished and J. let me hug her. A. caught my eye and mouthed "thank
you for helping my mother to smile." J. was quiet then, and I felt her
exhaustion. We agreed that it was time to close the piano for another
week, and I left. J. followed me to my car, and left me with "God bless
you."

This was an exhausting visit to J's home, yet it was even more
energizing because of the multiple caring moments I experienced with J.
and her family. I have come to believe that caring moments are unique
to each nursing situation and evolve naturally from the mutuality of
authentic presence as the fullness of the nurse's personhood blends
with the fullness of the other's personhood. Together they transcend the
moment. The caring moment is connectedness between nurse and other and
both experience moments of joy. (Kronk, 1992)

To characterize this nursing situation with a nursing diagnosis and to
portray it as a linear process driven by the diagnosis or problem to be
addressed with a pre-envisioned outcome would be to rob the situation
of all the beauty of nursing. Because a story of a nursing situation
is narrative, there is a temporal structure. However, this structure
supports rather than destroys the "lived experience" character of the
situation. The story of the nursing situation conveys the "all-at-once"
as well as the unfolding. This approach permits us to conceptualize as
well as contextualize the knowledge of nursing the story tells. Through
story, the meaning for this nurse of knowing herself as caring person,
as entering into the world of other(s) with authentic presence, is
understood. The nurse knows other as caring person, and in that knowing
attends to specific calls for caring with unique expressions of caring
responses created in the moment.

The Nursing as Caring theory, grounded in the assumption that all
persons are caring, has as its focus a general call to nurture persons
as they live caring uniquely and grow as caring persons. The challenge
then for nursing is not to discover what is missing, weakened, or
needed in another, but to come to know the other as caring person and to
nurture that person in situation-specific, creative ways. We no longer
understand nursing as a "process," in the sense of a complex sequence of
predictable acts resulting in some predetermined desirable end product.
Nursing is, we believe, processual, in the sense that it is always
unfolding and that it is guided by intention.

Nursing is a professional service offered in social contexts, most often
in bureaucratically organized health services. Discussions of health
services, overheard in boardrooms and legislative chambers, are
languaged in impersonal, aggregate, disembodying, and perhaps more
importantly, economic terms. In contrast to the accepted ritualization
of such language, nursing has a very important role to play--to bring the
human, the personal dimension to health policy planning, and health
care delivery systems. Clearly, it is nursing knowledge itself, of human
person, of person as caring, that has been missing. While other groups
rightly bring in knowledge of efficient operation and financing,
nursing's contribution to the dialogue on effective care has the
potential to remind all players of the real bottom line, the person
being cared for. We must remember that in most industrialized countries
health service is viewed as a commodity delivery system, an economic
exchange of goods and services. While this is not the only context
for nursing, it is the most prevalent context. If nurses choose to
participate in existing delivery systems, and most do, then ways must
be created that preserve the service of nursing while responding to the
appropriate requirements of the system. Ultimately, this would require
of nurses that they become skilled in articulating their service as
nursing, and connecting that service to the recording and billing
systems in use. Although this same goal animated the nursing diagnosis
movement of the 1970s, within the terms of that movement, the result
was less than fortunate: nursing's effort to emulate the fee-for-service
billing practices of medicine failed, and nursing contributions were
neither communicated nor reimbursed.

When nurses tell the stories of their nursing situations, however, the
service of nursing becomes recognizable. The unique contribution that
nurses make, expressed in the focus of nursing, emerges across settings.
The difference between a nursing story and a typical nursing case
report is striking; the first conveys the nursing care given, the second
reports the medical-assisting activities performed by the nurse. We have
discovered in our work with nurses that while nursing care is usually
given, it is frequently neither acknowledged nor communicated.

The nurse practicing within the caring context described here will most
often be interfacing with the health care system in two ways: first,
to communicate nursing in ways that can be understood; and second, to
articulate nursing service as a unique contribution within the system in
such a way that the system itself grows to support nursing.

The concept of profession is involved in the practice of nursing as
caring. With the advent of the information and action technologies
of the twenty-first century, the present concept of professions as
repositories of esoteric knowledge employed by social elites is rapidly
becoming outdated. As many nurses will attest, the patient often teaches
the nurse about new medical technologies and about the management of
them. In this regard, what will it mean, in the next century, to profess
nursing? A renewed commitment to professional caring means that nurses
would seek connectedness in all collegial relationships as nurses are
open to discovering the unfolding meaning of human caring, with persons
valued as important in themselves. Therefore, nurses forfeit assuming
authoritative stances toward each other, the persons nursed, and other
participants in the health care enterprise. More than ever, it will mean
that nurses will, in relation with others, live out the value of caring
in everyday life. Thus, the organized nursing profession would assume
responsibility for developing and sharing knowledge of nurturing persons
living caring and growing in caring.

The following story of a nursing situation, told in the form of a
poem, exemplifies the reconceptualization called for in the practice of
Nursing as Caring. In this situation, the nurse carried out a medically
prescribed treatment, not as a form of medicine but as a form of
nursing. The nurse communicates a knowing of the other as caring person,
living courage and hope in the face of pain and fear. This example
illustrates the meaning of knowing as a caring ingredient (Mayeroff,
1971), in the connectedness of the nurse with the patient.

The nurse's knowing both forms the intention to nurse and is formed by
the intention to know other as caring person and nurture caring. A
more typical recounting of this situation would focus on the specific
procedure of the treatment being applied, in terms of the condition of
the wound. In this poem, the nurse renders the meaning of nursing.

          Heating--HIV +
          Your wounds weeped
          Purulent with the discharge of our
          Pain and fear.
          They tried to hide, only to reappear.
          The treatment gentle, slow
          A warm, loving balm to your soul.
          Your stomach was fed the comfort
          Food of your youth
          And your lips drank in deeply all
          You knew and understood.
          The memories sweetened each moment
          You stood, face to face with terror of
          What might be mistook.
          All inside shifted as slowly it came,
          A gradual awakening; embracing of pain
          As you conquered your demons
          A lightness appeared
          To stay forever and
          Abolish all fears. (Wheeler, 1990)


NURSING SERVICE ADMINISTRATION

Many of the nursing situations described in this book have taken
place in hospital settings, where the nursing service is a shared
responsibility of many nurses in a range of functional roles. Nurses
in such settings generally nurse many persons intensively and
simultaneously and share direct nursing responsibility with one or
two other nurses. How can nurses in institutional practice settings be
supported so that calls for nursing can be heard and nursing responses
made? What is the role of the nurse administrator in supporting the
practice of nurses?

It is important to understand clearly the difference between the
practice of administration which happens to be delivered by nurses
and the practice of nursing administration. Tead (1951) defines
administration as "the comprehensive effort to direct, guide, and
integrate associated human strivings which are focused toward some
specific ends or aims" (p. 3). For example, goals of administration
could be business, governmental, education, or nursing. In this
definition, it is evident that the focus must be made clear. It is not
adequate to have an understanding of administration as a role which is
focused in functions such as interpersonal, informational, and
decisional. Such a perspective ignores the value of persons and the
ministering responsibilities inherent in the role. The administrator
must connect his or her work to the direct work of nursing.

Nursing administration by name suggests a groundedness in the
discipline. The role of the nursing administrator could indeed be
questioned if the focus of the administrative practice is not nursing.
There is the assumption that the administration of nursing is practiced
from a particular conception of nursing in which the focus or goal of
nursing is clear. What the nursing administrator says and does as nurse
must reflect the uniqueness of the discipline so that nursing's unique
contributions are assured. Nursing administrators must also be able to
articulate the unique contributions of nursing to other members of the
interdisciplinary health care team.

The relationship of the nurse administrator's role to direct care is
implicit in this perspective. The nursing administrator describes him or
herself as directly involved in the care of persons. All activities of
the nursing administrator are ultimately directed to the person(s)
being nursed. It is essential that this direct connection to the goal
of nursing be made and that persons assuming nursing administration
positions be able to articulate their unique role contributions to
nursing care. Without this clarity of focus, one may be engaged in the
practice of administration but not nursing administration.

From the viewpoint of nursing as caring, the nurse administrator makes
decisions through a lens in which the focus of nursing is nurturing
persons as they live caring and grow in caring. All activities in
the practice of nursing administration are grounded in a concern for
creating, maintaining, and supporting an environment in which calls for
nursing are heard and nurturing responses are given. From this point of
view, the expectation arises that nursing administrators participate
in shaping a culture that evolves from the values articulated within
nursing as caring.

Although often perceived to be "removed" from the direct care of the
nursed, the nursing administrator is intimately involved in multiple
nursing situations simultaneously, hearing calls for nursing and
participating in responses to these calls. As calls for nursing are
known, one of the unique responses of the nursing administrator is to
directly or indirectly enter the world of the nursed, understand special
calls when they occur, and assist in securing the resources needed
by the nurse to nurture persons as they live and grow in caring. All
nursing activities should be approached with this goal in mind. Here,
the nurse administrator reflects on the obligations inherent in the role
in relation to the nursed. The presiding moral basis for determining
right action is the belief that all persons are caring. Frequently,
the nurse administrator may enter the world of the nursed through
the stories of colleagues who are assuming other roles such as
nurse manager. Policy formulation and implementation allow for the
consideration of unique situations. The nursing administrator assists
others within the organization to understand the focus of nursing and to
secure the resources necessary to achieve the goals of nursing. When the
focus of nursing can be clearly articulated, nursing's contribution
to the whole will be understood, If the focus of practice is clouded,
however, this becomes an insurmountable task. Recognition of nursing's
value is contingent upon the ability of nurses to articulate their
contribution. Traditionally, systems define contribution through patient
outcomes and other total quality measures. Future articulation of
nursing and its contributions would emanate from the values and
assumptions offered in the Nursing as Caring theory.

Sharing nursing situations with others is one way to promote the knowing
of nursing. It also is a way for other members of the organization to
see how their roles contribute to the well-being of the nursed. The
following is a nursing situation, re-presented as the poem "Last
Rights," that cries out for nursing administration, that is, nursing
support for nursing.


                      Last Rights

          Tight faced, they found and cornered her at work
          As quick as hammers pounding down a wall of
          words came hard and nailed that little quirk of
          honest so fast she held the rail.

          "Who were you to say he was a dying man,
          though he lay white, his lifethread thin.
          How were you to know the speed his flying heart
          would race away from bone and shin.

          He was hopeless, yes, beneath that tent of
          filmy gauze, but who were you to say his fate
          was hinged in prayer-our magic spent.
          Who knows, he might have lived another day.

          "He held my hands, asked the truth," she said.
          Then turned away to smooth the empty bed.

                           --Yelland-Marino (1993)


The nurse administrator can nurture the living in caring and growing in
caring of the person in this story by creating ways to support the
nurse at the bedside in order that the call for hope of being known and
supported as caring person, not object, can occur. What are some of
the strategies that the nurse administrator could engage in which would
reflect the nursing focus?

Because budget determination is such a prominent matter for nurse
administrators, we will begin there. Budget decisions should be directed
from the perspective of what I ought to do as nurse administrator that
would have the greatest effect on nurturing persons being cared for in
their living and growing in caring. One aspect of budget essential to
this story is time--time for the nurse to focus on knowing self and other
colleagues. As Paterson & Zderad (1988) state, for nursing practice to
be humanistic, awareness of self and others is essential. The budget
should include time allocations for staff to participate in dialogues
focused on knowing self as caring person in order that calls, such as
the one in the previous story, can be heard. The notion of dialogue is
central to transforming ways of being with others in organizations. Bohm
(1992) refers to dialogue as creating "a flow of meaning in the whole
group, out of which will emerge some new understanding, something
creative" (p. 16). Persons engaged in dialogue are focused on trying to
understand situations as perceived through another's eyes in order that
new possibilities may be recognized. Through the allocation of time,
nursing staff come to better know self and other. Shared meanings
emerge which become the "glue or cement that holds people and societies
together" (p. 16). These opportunities for knowing self assist the
nurse to achieve, as Tournier (1957) would put it, a reciprocity of
consciousness with other.

Through the opportunity to better know self as caring person, the nurse
will learn to intentionally and authentically enter nursing situations
focused on knowing and supporting the nursed as they live caring and
grow in caring. Time for reflection and collegial dialogue is necessary
to maintain this nursing lens in a period of increasing responsibility.
Such time allocation communicates the commitment of the nurse
administrator to enhance the growth of the nurse in the discipline of
nursing.

To propose that the budgeting of time is one of the most essential tasks
of a nursing administrator may seem outrageously naïve in a time
when organizations seem to be interested only in bottom-line figures.
Ironically, however, the time allocation strategy offered here supports
the goal of cost containment. Studies have shown that caring behaviors
of nurses (Duffy, 1991) and nursing staff attitudes (Cassarea et al.,
1986) are directly related to patient satisfaction. Benner and Wrubel
(1989) also found that caring is integral to expert practice. As a
result, and from the standpoint of quality of care as revenue producing,
this strategy of allowing time for dialogue and reflection has merit.

From the viewpoint of the Nursing as Caring theory, the nurse
administrators' beliefs about person would require that new ways
of being with the nursed are created and supported. The nursing
administrator models a way of being with others that portrays respect
for person as caring. Through modeling, others grow in their competency
to know and express caring. Of course creating and sustaining
environments that nurture and value the practice and study of nursing
remains the challenge facing nurses caught in the maze of various
organizational structures. Systems tend to perpetuate existing ways of
being even though their members may repeatedly question the legitimacy
of actions flowing from these structures. It is our belief that
nursing can create a culture that values caring within systems and
organizations. Systems and organizations can be reshaped and transformed
through living out the assumptions and values inherent within nursing as
caring.

Assumptions on which Nursing as Caring is built serve as stabilizers for
the organization. These assumptions directly influence the climate of
the organization and serve as the organizational pillars. The climate of
organizations is determined by beliefs and values of persons within it.
An organization grounded in the assumptions of person as described in
Chapter 1 would not support arbitrary and capricious decision making
in which the input of all persons has not been discerned. Mission
statements, goals, objectives, standards of practice, policies and
procedures emerge from assumptions, beliefs, and values that emphasize
one's humanness. If one accepts the assumption that persons are
caring by virtue of their humanness, then it follows that cultures are
comprised of caring persons. Respect for person as person is engendered
within this context. There is a desire to know and support the living of
caring; to support each other in being who we are as caring persons in
the moment. Therefore, assumptions of Nursing as Caring ground not only
the theory but may likewise influence the ontology of the organization
itself.

Generally, organizational structures reflect bureaucratic values.
Structures imply ways of being with and relating to people. The process
of relating is typically illustrated in a hierarchical fashion. The
concept of hierarchy carries with it the notion that there is a
"top" and a "bottom." Competition, levels, and positions of power
are implicit. In climbing the rungs of a bureaucratic ladder, it is
difficult for the employee to be authentic and valued as a unique person
with special ideas because the risks of such valuing are often too great
for the bureaucracy to bear. Competition too remains the driving force
of most organizations.

Within an organization, however, we can imagine each person's hands as
clinging to the rungs of the bureaucratic ladder. Taken further, this
image would clearly portray persons who are not and can not be open to
receive and know other. Because of the vertical axis of the bureaucratic
hierarchy, persons, more often than not, are viewed as objects. The
ladder positions people so that they are either looking up or down but
rarely eye-to-eye. Obviously, the hierarchical model does not support
the idea of each person as important in and to him or herself.

By contrast, and from the assumptions posited in Nursing as Caring, the
model for being in relationships resembles a dance of caring persons
(Boykin, 1990). The same persons are present in this circle that were in
the hierarchical structure described above. The difference between the
two models is the philosophical way of being with other. Because the
nature of relating in the circle is grounded in a respect for and
valuing of each person, the way of being is diametrically opposed to
traditional patterns of relating in organizations. Leaving the security
provided by known hierarchical structures, however, requires courage,
trust, and humility. Building on the assumptions of this theory, one can
infer that the basic dance of all persons in relationships is to know
self and other as caring person. Each person is encouraged and supported
in a culture that values person-as-person, person as caring.


[Illustration: Dancing Circle]

The image of a dancing circle is also used to describe being for and
being with the nursed. In the circle, all persons are committed to
knowing self and other as living and growing in caring. Each dancer
makes a distinct contribution because of the role assumed. The dancers
in the circle do not necessarily connect by holding hands although they
may. Each dancer moves within this dance as called forth by the nature
of the nursing situation. The nursed calls for services of particular
dancers at various points in time. Each person is in this circle because
of their unique contribution to the person being cared for ... nurses,
administrators, human resources, etc. These roles would not exist if it
were not for the nursed. There is always room for another person to join
the dance. Rather than the vertical view described earlier, this model
fosters knowing other. Eye-to-eye contact assists one to know and
appreciate each other as caring persons. Each person is viewed as
special and caring. No one person's role is more or less important than
the other's. Each role is essential in contributing to the process of
living grounded in caring. As each person authentically expresses their
commitment in being there for and with the nursed, caring relationships
are lived. When the focus in any health care institution fails to be
the person cared-for, purpose, roles, and responsibilities become
depersonalized and bureaucratic rather than person-centered and caring.

Personal knowing--knowing of self and other--is integral to the
connectedness of persons in this dance. The nursing administrator
interfaces with persons of many disciplines as well as with the nursed.
With each interaction, the nurse administrator is honest and authentic
in encouraging others to know and live out who they are. Each encounter
with another is an opportunity for knowing other as caring person.
From an organizational standpoint the nursing administrator assists
in creating a community that appreciates, nurtures, and supports each
person as they live and grow in caring moment to moment. The nursing
administrator assists nurses to hear and understand the unique calls for
nursing and supports and sustains their nurturing response.


REFERENCES

  Benner, P, & Wrubel, J. (1989). The primacy of caring: Stress and coping in health in illness. CA: Addison-Wesley.
  Bohm, D. (1992). On dialogue. Noetic Sciences Review, pp. 16-18.
  Boykin, A. (1990). Creating a caring environment: Moral obligations in the role of dean. In M. Leininger & J. Watson (Eds.), The caring imperative in education. New York: National League for Nursing, pp. 247-254.
  Cassarrea, K., Millis, J., & Plant, M. (1986). Improving service through patient surveys in a multihospital organization. Hospital and Health Services Administration, 31 (2), 41-52.
  Duffy, J. (1992). The impact of nurse caring on patient outcomes. In Gaut, D. (Ed.). The
  presence of caring in nursing. New York: National League for Nursing, pp. 113-136. Gadow, S. (1984). Touch and technology: Two paradigms of patient care. Journal of Reli-
  gion and Health, 23,63-69.
  Kahn, D., & Steeves, R. (1988). Caring and practice: Construction of the nurse's world. Scholarly Inquiry for Nursing Practice, 2 (3), 201-215.
  Knowlden, V. (1986). The meaning of caring in the nursing role. Dissertation Abstracts International, 46 (9), 2574-A.
  Kronk, P. (1992). Connectedness: A concept for nursing. Unpublished manuscript.
  Little, D. (1992). Nurse as moral agent. Paper presented at University of South Florida Year of Discovery Seminar, Sept. 1992.
  Mayeroff, M. (1971). On caring. New York: Harper & Row.
  Orlando, I (1961). The dynamic nurse-patient relationship. New York: G.P. Putnam's Sons. Paterson, J., & Zderad, L. (1988). Humanistic nursing. New York: National League for Nursing.
  Riemen, D. (1986a). Noncaring and caring in the clinical setting: Patients' descriptions. Topics in Clinical Nursing, 8,30-36.
  Riemen, D. (1986b). The essential structure of a caring interaction: doing phenomenology. In P. Munhall & C. Oiler (Eds.). Nursing research: A qualitative perspective. Norwalk, CT: Appleton-Century-Crofts.
  Roach, S. (1987). The human act of caring. Ottawa: Canadian Hospital Association. Samarel, N. (1988). Caring for life and death: Nursing in a hospital-based hospice. Dissertation Abstracts International, 48 (9), 2607-B.
  Swanson-Kauffman, K. (1986a). Caring in the instance of unexpected early pregnancy loss. Topics in Clinical Nursing, 8,37-46.
  Swanson-Kauffman, K. (1986b). A combined qualitative methodology for nursing research. Advances in Nursing Science, 8,58-69.
  Swanson, K. (1990). Providing care in the NICU: Sometimes an act of love. Advances in
  Nursing Science, 13 (1), 60-73.
  Tead, 0. (1951). The art of administration. New York: McGraw-Hill.
  Tournier, P. (1957). The meaning of persons. New York: Harper & Row.
  Wheeler, L. (1990). Healing-HIV+. Nightingale Songs, P.O. Box 057563, West Palm Beach,
  FL 33405-7563, 1 (2).
  Winland-Brown, J., & Schoenhofer, S. (1992). Unpublished research data. Yelland-Marino, T. (1993). Last rights. Nightingale Songs, P.O. Box 057563, West Palm Beach, FL 33405-7563, 3 (1).


[Illustration: Button]


CHAPTER V. -- IMPLICATIONS FOR NURSING EDUCATION

In this chapter, we address the implications of our theory for nursing
education, including designing, implementing, and administering a
program of study. The assumptions that ground Nursing as Caring
also ground the practice of nursing education and nursing education
administration. The structure and practices of the education program
are expressions of the discipline and, therefore, should be explicit
reflections of the values and assumptions inherent in the statement of
focus of the discipline. From the perspective of Nursing as Caring, all
structures and activities should reflect the fundamental assumption that
persons are caring by virtue of their humanness. Other assumptions and
values reflected in the education program include: knowing the person as
whole and complete in the moment and living caring uniquely; understand
that personhood is a process of living grounded in caring and is
enhanced through participation in nurturing relationships with caring
others; and, finally, affirming nursing as a discipline and profession.

The curriculum, the foundation of the education program, asserts the
focus and domain of nursing as nurturing persons living caring and
growing in caring. All activities of the program of study are directed
toward developing, organizing, and communicating nursing knowledge, that
is, knowledge of nurturing persons living caring and growing in caring.

The model for organizational design of nursing education is analogous
to the dancing circle described earlier. Members of the circle include
administrators, faculty, colleagues, students, staff, community, and the
nursed. What this circle represents is the commitment of each dancer to
understanding and supporting the study of the discipline of nursing. The
role of administrator in the circle is more clearly understood when the
origin of the word is reflected upon. The term administrator is derived
from the Latin ad ministrare, to serve (Guralnik, 1976). This definition
connotes the idea of rendering service. Administrators within the circle
are by nature of role obligated to ministering, to securing and to
providing resources needed by faculty, students, and staff to meet
program objectives. Faculty, students, and administrators dance together
in the study of nursing. Faculty support an environment that values
the uniqueness of each person and sustains each person's unique way
of living and growing in caring. This process requires trust, hope,
courage, and patience. Because the purpose of nursing education is to
study the discipline and practice of nursing, the nursed must be in the
circle. The community created is that of persons living caring in the
moment, each person valued as special and unique.

We have said in Chapter 1 that the domain of a discipline is that which
its members assert. The statement of focus that directs the study of
nursing from this theoretical perspective is that of nurturing persons
as they live caring and grow in caring. The study of nursing is
approached through the use of nursing situations. The knowledge of
nursing resides in the nursing situation and is brought to life through
study. The nursing situation is a shared lived experience in which the
caring between the nurse and the one nursed enhances personhood or the
process of living grounded in caring. These situations, like the many
cited in earlier chapters, become available for study through the use of
story (recounting the situation in ways that convey the essence of the
lived experience). These stories create anew the lived experience of
caring between the nurse and the nursed, and bring to life the basic
values described in Chapter 1.

Story then becomes the method for studying and knowing nursing. Carper's
(1978) four patterns of knowing serve as an organizing framework for
asking epistemological questions of caring in nursing. Those patterns
include personal, ethical, empirical, and aesthetic knowing. Each of
these patterns comes into play as one strives to understand the whole of
the situation. Personal knowing centers on knowing and encountering self
and other, empirical knowing addresses the science of caring in nursing,
ethical knowing focuses on what "ought to be" in nursing situations,
and aesthetic knowing is the integration and synthesis of all knowing
as lived in a particular situation. The poem, "Intensive Care," a
representation of a nursing situation, is given here to illustrate the
organization of sample content.


                    INTENSIVE CARE
                       (centered)

        Did you see nurse that you can know me--
        The part that is me, my mind and soul is in my eyes
        These tubes that are everywhere-that is not me.
        The one in my throat is the worse of all--
        Now my whole being, the essence of me I
        must reflect
        through my hands but they are tied down,
        movements
        of my head but did you realize that
        uncomfortable for me
        or through my eyes and you do not notice them--
        except once today during my bath.
        You speak to me and look at the tubes--
        Don't you know my thoughts are all over my face
        Don't you realize your thoughts are on your face--
        In your touch and your tone of voice.
        I wrote a request on paper and you said "I'll take care
        Of it for you" your tone said "Why can't this
        woman
        Do anything for herself?"
        You positioned your hand to count my pulse but I
        Can't say you touched me-you wouldn't hold my
        hand that I may touch you.
        You walked in for the first time today with a grin
        on your face but your mouth is now tight
        you grimaced a lot as you bathed me.
        Don't you see nurse that you can know me--I'm not
        A chart or tubes of medication, monitors or all
        the other things you look at so intensely--I'm
        more than that
        I'm scared--just look in my eyes.
                          --S. Carr, 1991


Carper's (1978) patterns of knowing offer a framework for organizing the
content for studying this nursing situation.


PERSONAL KNOWING

  Who are the nurse and nursed as caring persons in the moment?
  How are the nurse and nursed expressing caring in this moment?
  What is the meaning of this situation to the nurse and nursed in
       terms of present realities and future possibilities?
  What is the meaning of vulnerability and mortality?
  What is the value of intuition in practice?
  Empirical Knowing
  What nursing and related research exists on modes of communication,
        the meaning of presence in practice, touch, objectification,
        recovery of cardiac patients, technological caring,
        understanding the experience of fear and loneliness?
  What factual knowledge is needed to be competent in this particular
        situation--e.g. knowledge of monitors, chest tubes,
         medications, cardiac care, diagnostic data?


ETHICAL KNOWING

  If nursing is practiced from the perspective of Nursing as Caring,
        what obligations are inherent in this situation?
  How is the nurse demonstrating the value that all persons are caring?
        Respect for person-as-person? Interconnectedness?
  What dilemmas are present in this story?


AESTHETIC KNOWING

  How is the nursed supported to live dreams of living and growing in caring?
  How could the nurse transcend the moment to create possibilities
        within this specific nursing situation?
  What metaphors might express the meaning of this nursing situation?


Students studying this nursing situation are challenged to know the
person as caring, as living caring uniquely in the moment, as having
hopes and dreams for growing in caring, and as being whole or complete
in the moment. The student is also challenged to know the nurse as
caring person in the moment and to project ways of supporting the nurse
as caring person.

Through the study of this situation, students and faculty identify
a range of calls for nursing as well as nurturing responses. In this
process, there is dialogue focused on knowing the nurse and nursed in
the story as caring person. We would contribute the following as our
knowing of the nursed as caring person. Through her honest expression of
"I'm scared--just look in my eyes," we know her as living hope, honesty,
and transcending fear through courage.

Calls for nursing might include a call to be known as caring person and
a call to have interconnectedness recognized and affirmed. The nurse's
response to these calls is individual and evolves from who one is as
person and nurse. Therefore, the range of responses is multiple and
varied--each reflecting the nurse's informed living of caring in the
moment. Each nurturing response is focused on nurturing the person as
he or she lives caring and expresses hopes and dreams for growing in
caring.

If the nurse is responding to the call of the person for recognition
and affirmation of interconnectedness, perhaps the nurse would express
hearing this call by being present with the intention of knowing
other as caring person. This may be communicated through active
patience--giving the other time and space to be known; through touch
which communicates respect and interconnectedness; through the nurse
sharing who he or she is as caring person in this relationship--perhaps
through tears as the resonance of commonality of this experience is
known; through music or poetry if a shared love of these has been
discovered.

Through dialogue, students and faculty openly engage in the study of
nursing. The dialogue encourages and supports students and faculty to
freely express who they are as person and nurse living caring through
the re-presented story. It provides an opportunity to affirm values
of self and discipline and to study how these values may be lived in
practice. It is in this dialogue of nursing that faculty communicate
their love for nursing. Time is needed for both faculty and students
to reflect on the meaning of being a member of this discipline and more
specifically, on the meaning of being a member of a discipline
focused on nurturing persons as they live and grow in caring. Dialogue
facilitates the integration of this understanding and is a key concept
in present and future transformations of nursing education. Common
engagement in dialogue as nursing stories are shared and studied is the
way of being.

The story lived anew provides students the opportunity to participate
in a lived experience of nursing and to create new possibilities. Since
nursing can only occur through intentionality and authentic presence
with the nursed, students and faculty share how they prepare to enter
the world of the nursed, and how they come to understand that world.
This process requires that students be encouraged to live fully their
personhood. To facilitate such living, faculty support an environment in
which students are free to choose and to express self in various ways.
For example, perhaps the holistic understanding of a nursing situation
would be expressed as aesthetic knowing through dance, poetry, music,
painting, or the like. We view this process of education as critical to
moral education. When students enter nursing situations to know other as
living and growing in caring, they are living out the moral obligation
that arises from the commitment to know person as caring. Here, then,
is an expression of a dynamic view of morality in which caring is always
lived in the moment.

In the study of the situation, Intensive Care, brought to the dialogue
are personal experiences of being alone, being afraid, and being with
someone and not being heard or seen as caring person. This
personal knowing fosters human awareness of our connectedness and
interdependence. In this context, the nurse does not study the empirics
of cardiac pathology to understand a perceived deficit but rather to
become competent in drawing forth the knowledge that is specific to
knowing this person as whole in the moment. The nurse comes to know
the person as living caring and growing in caring, situated within
a particular set of circumstances, some of which the nurse knows
explicitly. Each student entering the nursing situation will ask,
"How can I nurture this person in living and growing in caring in
this situation?" Because each nurse may hear calls for caring in many
different ways, nursing responses are many and varied. For nursing
faculty, openness to multiple possibilities presents a particular
challenge and an opportunity to suspend entrenched patterns of teaching
nursing.

Faculty and students study nursing together. Faculty join students in a
constant search to discover the content and meaning of the discipline.
Undoubtedly, this understanding of extant possibilities presents a
different view of the role of teacher. Yet, it is a view that engenders
the sort of humility essential to nursing for there is always more
to know. Although past methods of teaching of nursing may have been
comfortably structured through textbooks organized around medical
science, faculty are now empowered to question what should be the focus
of study in the discipline of nursing. Faculty are encouraged to take
risks and let go of the familiar. The perspective that Nursing as Caring
conveys--the fullness and richness of nursing--will allow faculty to
willingly assume the risks inherent in a new way of guiding the study of
nursing.

In teaching Nursing as Caring, faculty assist students to come to know,
appreciate, and celebrate self and other as caring person. Mayeroff's
On Caring (1971) provides a context for the generic knowing of self as
caring. Through dyads or small groups, students share life situations
in which they experienced knowing self and other as caring person.
Mayeroff's caring ingredients (knowing, alternating rhythm, trust,
honesty, hope, courage, humility, patience) also serve as a source for
reflection as one asks "who am I as caring person?". As students engage
in this exercise, their emerging reflections begin to ground them as
they grow in their understanding of person as they live and grow in
caring. Students will also draw on the knowledge gleaned in the study
of arts and humanities as they attempt to gain a deeper understanding of
person. The process of knowing self and other as caring is lifelong. In
an educational program grounded in Nursing as Caring, however, the focus
on personal knowing (in the study for every nursing situation) provides
a deliberate opportunity for greater knowing of self and other as caring
person.

Students, as well as faculty, are in a continual search to discover
greater meaning of caring as uniquely expressed in nursing; journaling
is an approach that facilitates this search. For example, in a special
form of journaling, students actively dialogue with authors whose works
they are reading and with the ideas expressed in their works. This
process enhances the students' understanding of caring in nursing.
Over time, students integrate and synthesize many ideas and create new
understandings. Examination is another process to facilitate learning.
From this theoretical perspective, essay examinations that present
nursing situations provide opportunities for students to express their
knowledge of nurturing persons living and growing in caring. Aesthetic
projects also allow the student the opportunity to communicate
understanding of a nursing situation. We would like to share with you
a project from a course in which the students were asked to express the
beauty of a nursing situation. In this nursing situation, the nurse,
Michelle, shared her gifts of therapeutic touch and voice as expressions
of caring for David in the moment, drawing on an earlier dialogue in
which David told her of his love of meditation and the Ave Maria, she
wrote:


                AVE MARIA
          AND THERAPEUTIC TOUCH
                FOR DAVID

          "David, let me know your pain;
          From fractured leg and heart,
          Share with me your private hell.
          Next to one who's far,
          Far away his own world:
          Moaning, crying, weak.
          What's it like to lie beside
          One who cannot speak?

          "Tell me David, what you do
          To cancel out the sound;
          Eliminate the smell of dung
          In which your roommate's found?
          Who can you complain about?
          Are you worse off than he?
          Tied to IV, traction lines
          You cannot be free.

          "David, I can see your pain.
          Tell me where you are.
          Tied in bed. Powerless.
          From loved ones you're apart.
          I can't move you from this place
          To take your pain away.
          But let me lay my hands on you
          And sing to you today."

          Ave Marie, gratia plena
          Maria, gratia plena.
          Ave dominus, dominus tecum.
          Benedicta to in mulieribus.
          Et benedictus
          Et benedictus, fructus ventris;
          Ventris tui, Jesu.
          Ave Maria

          I sang the song he loved and used
          To meditate and flee,
          Escape tormenting stimuli.
          He needed to be freed,
          To understand why he must bear
          This trial, this hell, this pain,
          I sang the tune; I touched with care
          To give him peace again.

                        --Stobie, 1991


Expressions of nursing such as this, which was partly sung, beautifully
portray the living of caring between the nurse and the nursed and
exemplify how caring enhances personhood. Faculty play a vital role in
fostering in students the courage to take such risks. Faculty encourage
self-affirmation in students, open, nonjudgmental dialogue, living the
caring ideal in the classroom and development of the students' moral
groundedness in caring (Boykin & Schoenhofer, 1990). Faculty also take
the risk of sharing self through their stories of nursing. The sharing
of nursing situations is, in essence, a sharing of our innermost core
of common identity and forms a type of collegiality among those who are
studying the discipline together.

How can faculty be supported to teach nursing in new ways? The
administrator of the program fosters a culture in which the study of
the discipline from the caring perspective, as presented here, can be
achieved freely and fully. All actions of the dean are directed toward
creating, maintaining, and supporting this goal. The theoretical
assumptions ground the activities of the dean in both internal and
external areas of responsibility.

Internally, the administrator, faculty, staff, and students model
commitment by creating an environment that fosters the knowing, living,
and growing of persons in caring. The dean "ministers" by assuring that
faculty, students, and staff are presented ongoing opportunities to
know themselves ontologically as caring persons and professionals and
to understand how caring orders their lives. Who we are as person
influences who we are as student, colleague, nurse, scholar, and
administrator. Therefore, attention must be directed to knowing self.
Time must be devoted to knowing and experiencing our humanness.

The constant struggle to know self and other as caring person nourishes
our knowing of the nursed. Through constant discovery of self, the other
is also continually discovered. This culture sensitizes each person
to ways of being with other that necessitate that each action reflect
respect for person as person. Therefore, when issues are to be
addressed, they are addressed openly and fully. Persons are encouraged
to bring forth who they are so there is congruence between actions and
feelings. Understanding each other's views is essential to the unfolding
of this culture. Dialogue assists one to know the other's needs and
desires, and to image oneself in the other's place. As such, the dean,
faculty, staff, and students become skilled in the use of the caring
ingredients, internalized as personally valid ways of expressing caring:
knowing, alternating rhythms, trust, hope, courage, honesty, humility,
and patience (Mayeroff, 1971).

Of utmost importance in fostering this culture are decisions regarding
selection of faculty. Although many prospective faculty have a fairly
traditional lens for the study of nursing (that is, the lens of medical
science or frameworks borrowed from other disciplines), this actually
becomes an insignificant factor in the process of selection. At the
heart of choosing new faculty is knowing their passion for and love of
nursing. A focus of the interview process is discerning the person's
devotion to the discipline. It is our belief that this attitude, this
love of nursing, is the music for the dancers in the circle. One way
to know if prospective faculty love nursing is to ask them to share
a significant story from practice. Having faculty share a story
illuminates their conceptualization of the discipline. Many faculty who
have not had the opportunity to teach nursing through an articulated
nursing lens, can yet communicate nursing clearly through story.

Faculty are supported in their struggles to conceptualize nursing in
a new way. Forums in which faculty come together and aesthetically
re-present and share their nursing story is one strategy that
effectively engages self and other in the knowing of nursing. It is also
a wonderful way to orient faculty as to how to use nursing situations to
teach nursing. Faculty support each other as colleagues in learning
to teach nursing in a new way, in becoming expert in the practice of
nursing education, and in living out the basic assumptions of this
theory. This need for support holds true not only for faculty-faculty
relationships but for all relationships. The comfort of faculty teaching
nursing from the perspective of Nursing as Caring is enhanced as the
value of knowing other as caring, as living our histories and as having
special nursing stories to share is appreciated.

The administrator, faculty, and staff assist in fostering an environment
that furthers the development of the students' capacity to care.
Competency in caring is a goal of the educational process. Students are
continually guided to know self and other as caring person as faculty
and administrators model actions that reflect respect for person as
person. Each student is known as caring person, as special and unique.
Policies allow for consideration of individual situations and diverse
possibilities. In this culture, the dean and faculty attempt to know the
student as caring person and student of the discipline. The intention of
the dean to know students in this way can be evident through invitations
for regularly scheduled dialogue in which students share openly their
conceptions about nursing. The administrator is truly with students to
know them as caring persons and to hear from them their understanding of
nursing as caring.

Externally, the dean "ministers" to faculty, students, and staff through
securing resources necessary to accomplish program goals. The dean
articulates to persons in the academic and broader community their
role in the dance of nursing. The role of these persons is to provide
resources such as scholarships, faculty development possibilities,
learning resources, and research monies. Although this may be a primary
responsibility of the dean by nature of the role, all persons in the
circle share in this process by virtue of their commitment to nursing.

The administrator brings to the circle a skillful use of the caring
ingredients. Alternating rhythms are used to understand and appreciate
each person's unique contributions that support the achievement of
program goals. For example, the budgetary process is essential to
creating an environment that reflects the valuing of nursing. Commitment
of the dean to securing resources necessary to accomplish the program
goals drives the budget rather than the budget driving the commitment.
The administrator's devotion to the discipline and to the basic
assumptions of the theory direct all activities. The administrator makes
decisions that reflect the basic beliefs of this theory. All decisions
would ultimately be made from this standpoint: "What action should
I take as administrator which would support the study of nursing as
nurturing persons living in caring and growing in caring?"


What we have tried to suggest here is that every aspect of nursing
education is grounded in the values and assumptions inherent in this
theoretical focus. Thus, not only is the curriculum a direct expression
of Nursing as Caring, but all aspects of program are similarly grounded.


REFERENCES

  Boykin, A., & Schoenhofer, S. (1990). Caring in nursing: Analysis of extant theory. Nursing Science Quarterly, 4, 149-155.
  Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1, 13-24.
  Carr, S. (1991). Intensive Care. Nightingale Songs, PO. Box 057563, West Palm Beach, FL 33405-7563, 2 (1).
  Guralnik, D. (1976). Webster's new world dictionary of the American language. Cleveland: William Collings + World Publishing Co.
  Mayeroff, M. (1971). On caring. New York: Harper & Row.
  Nodding, N. (1988). An ethic of caring and its implications for institutional arrangement. American Journal of Education, 97, 215-230.
  Roble, M. (1991). Ave Maria and Therapeutic Touch for David. Nightingale Songs, P.O. Box 057563, West Palm Beach, FL 33405-7563, 1 (3).



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CHAPTER VI -- THEORY DEVELOPMENT AND RESEARCH

In this chapter, we will address our conception of nursing as human
science and suggest directions and strategies for further development of
the theory of Nursing as Caring. We initially introduced our perspective
of nursing as discipline and profession in Chapter 1 and as a grounding
context for the theory. As a discipline, nursing is a way of knowing,
being, valuing, a way of living humanely, connected in oneness with
others, living caring and growing in caring. The unity nursing offers
is known in human experience through personal, empirical, ethical, and
aesthetic realms.

Science has to do with knowing and that which is known. Philosophers of
science are concerned with valid ways of knowing and ways of validating
that which is known. Human science is described by scholars in various
ways, each emphasizing particular values but all connecting to a common
understanding that human science is concerned with knowing the world
of human experience. A committed inquiry into human experience seems to
call forth certain values related to the meaning of being human.
Herein lies the fundamental difference between formal science and human
science, as we perceive it. Formal science, that which is practiced in
the natural sciences and other sciences that emulate them, is modeled
on the structure of mathematics. Mathematics is a highly lawful science
that has contributed enormous social benefits over time. However,
formal science grounded in mathematics and languaged as calculus is an
inappropriate approach to the study of person-as-person. A perspective
that addresses the phenomenon of person-as-person is grounded in central
values such as caring, freedom, and creativity. Methods to study person
must be similarly grounded.

We have come to understand that valid ways of knowing nursing and
legitimate warrants for nursing knowledge are discovered from within
the study of nursing itself; that is, within the study of the nursing
situation. The manner in which certain disciplines are conceptualized,
especially those dealing in normative contexts, calls for a dialectical
form of sciencing, comparing, and contrasting. However, coming to know
nursing is a dialogical process--direct engagement with the "word of
nursing." Nursing science must be contextual; the decontextualized
methodology of formal science, while essential for certain disciplines,
cannot reveal direct knowledge of nursing. Because of the nature
of nursing, nursing science must permit intentionality, intimacy,
mutuality, and particularity.

Human science has understanding as its goal, with the definite
expectation that understanding is in the moment only (Watson, 1988; Van
Manen, 1990). In addition, the nature of nursing praxis does not
require knowledge for the purpose of control, but for enlightenment,
moment-to-moment and reflectively. The nurse seeks knowledge neither to
control one's own behavior or that of the nursed. If it were otherwise,
the nurse would become his or her own prisoner, and would relate to
the other as dominator rather than caring nurse. The concept of the
hermeneutic circle informs our understanding of the nature of nursing as
a human science. This circle of understanding, really a sphere more
than a uni-dimensional circle, is a heuristic device which directs our
attention. As attention pauses at any aspect of the nursing situation,
we must attend to other aspects and to the whole of the nursing
situation to create useful understanding. One hermeneutist has pointed
out that the circle brings us further along, not the issue at hand
(Droysen, 1988). This distinction points to the human science position
that understanding is not constituted through analysis of facts but
through dialogue with text and context. That is, what moves within the
circle is the seeker, rather than that which is sought, so that many
aspects are illuminated in context, and understanding grows. The
hermeneutic circle requires that what we note in our inquiry remains
contextualized, developing "new and ever new circles" (Boeckh, 1988).
This is in contrast to normal science that requires an external referent
for objects of study in order to avoid circular thinking. Heidegger
(1988), for example, contrasts the vicious circle of normal science
(tautology) with the circle of hermeneutic: " . . . in the circle is
hidden a positive possibility of the most primordial kind of knowing"
(p. 225). We would propose that valid knowing in nursing is that which
is known from within the circle.

While the work of several scholars has influenced our understanding
(e.g., Gadamer, 1989; Van Manen, 1990; Ray, 1994; Reeder, 1988),
Macdonald's (1975) interpretation from the field of humanistic
education is especially meaningful. He explains hermeneutic knowing
methodologically as "circular rather than linear in that the
interpretation of meaning in hermeneutic understanding depends on a
reciprocal relation" (p. 286) rather than on a fixed normative reference
point. The hermeneutic circle models the idea of reciprocal relation,
but Macdonald goes further to call for a self-reflective science that
will "transcend problems of monological and hermeneutic meaning" (p.
287). The nature of nursing as expressed in the Nursing as Caring theory
is a reciprocal relation, one characterized by its grounding in person
as caring, and as persons connected in oneness in caring. Sciencing in
nursing from this perspective must go beyond linearity to encompass the
dialogic circling involved in the nursing situation. This places the
discipline of nursing among the human sciences, and calls for methods
of inquiry that assure the circle or dialogue, and further, fully
accommodate that which can be known of nursing.

Nursing is properly catalogued as one of the human sciences for
many reasons. The most basic reason is that the discipline and the
disciplined practice of nursing directly involve persons in the fullness
of their humanness. From our perspective, this means person as caring.
Person as caring implies person in community, connected in oneness
with others and with the universe, person freely choosing the living of
values which are expressions of caring. This nursing ontology requires
an epistemology consonant with human science values and methods. To know
of, through and with nursing necessitates methods and techniques that
honor freedom, creativity, and interconnectedness.

In Chapter 4, we asserted that nursing knowledge is created and
discovered within and from within the nursing situation. (Nursing
situation, you may recall, is understood as a shared lived experience
in which the caring between the nurse and the one nursed enhances
personhood.) Therefore, because the locus of nursing inquiry is the
nursing situation, the systematic study of nursing calls for a new
methodology that recognizes that fact.

Certainly, we acknowledge that something useful for nursing can be
learned through existing methodologies, from both natural and human
science traditions. For example, an experimental design can produce
information about the effectiveness of a given clinical technique within
a specified range of use (e.g., placement of an oral thermometer). Such
information can be important and useful to the work of the nurse and
useful to the client of nursing. It tells us nothing, however, of
nursing. In fact, the central tenet underlying measurement in normal
science directly contradicts the central tenet of human science: created
versus creating. Thus, the fullness of the nursing situation is not
amenable to study by measurement techniques. Yet, aspects of the nursing
situation can be abstracted and studied as variables in relation to
other variables. This does not, however, yield knowledge of the nursing
situation in its fullest. At best, measurement approaches can call
attention to an aspect so that it can be considered within the
unfolding.

Phenomenology, on the other hand, offers an example of an orientation
and methodology that more closely approximates what is needed in a
nursing method of inquiry. Phenomenology is an orientation toward
inquiry that may be actualized through any one of a number of generic
approaches, but is generally understood as the study of lived experience
(e.g., Van Manen, 1990; Oiler, 1986). When the phenomenon conceptualized
for study is representative of the nursing situation, nursing may be
known. That is, new nursing knowledge may eventuate. New understanding
of the meaning of the shared lived experience of caring between nurse
and nursed enhancing personhood can be created.

Yet, for the purposes of nursing, phenomenology also has its limits.
For example, when phenomena which have been abstracted from a nursing
situation are selected for study (that is, when phenomena are taken out
of context), results of the inquiry cannot generate knowledge of nursing
proper. For example, the understanding that comes in developing a
description of the essential structure of what it is like for a nurse
to be called to nurse informs us about nurses, but not about nursing
directly. Similarly, an exquisite phenomenological description of what
it is like for a person to live grieving is helpful in understanding the
person. However, it should not be mistaken for knowledge of nursing, but
knowledge which illuminates the study of nursing when taken back to
the full context of the nursing situation. Further, the various
phenomenologies in the literature come from frames of reference that are
not nursing (e.g., existential psychology or educational psychology),
and thus impose a "silent" borrowed framework when used to study
nursing.

Is this drawing too fine a line? And is it really important to press
the issue of nursing knowledge versus knowledge of and for nurses?
The answers to these questions are probably found in one's concept
of nursing as a field of knowledge (discipline) and a human service
(profession). It seems that nursing and nurses have suffered
significantly over the years with this dilemma. Is it possible to have
a sense of self as nurse without a concomitant sense of nursing as
a discipline which is more than tacit and to which one is committed?
Students of nursing and practitioners alike have abundant opportunities
to acquire a sense of self as nurse. Yet why is it that many programs of
nursing education (at all levels) do not convey a sense of nursing as
a discipline? The answer may lie in those conducting the programs, who
have experienced training for practice and education in disciplines
other than nursing and without explicit education in the discipline of
nursing.

From the perspective of Nursing as Caring, with its grounding in person
as caring and nursing as discipline, the distinctions implied in this
question of "does it really matter" are of central importance. Nurses
in practice, education, and administration continue to address nursing
primarily in terms of "what nurses do," (e.g., nursing "interventions")
and most nursing research seems to derive from that perspective as
well. Without a clearly articulated understanding of the focus of the
discipline, it has been extremely difficult to organize and structure
nursing knowledge in ways that facilitate the development of the
discipline. In this book, we have offered a theory, Nursing as Caring,
as one expression of that focus, languaged in terms that communicate the
essence of nursing.

Nursing knowledge is knowledge of nurturing persons living caring and
growing in caring within shared lived experiences in which the caring
between nurse and nursed enhances personhood. Furthering nursing
knowledge requires methods that can illuminate the central phenomenon of
the discipline. The development of such a methodology is, as we see it,
the next major effort to be undertaken in the development of the theory.
In this regard, we envision a fully adequate methodology that would
include a phenomenological aspect which goes beyond description to a
hermeneutical process, within an action research orientation. That is,
what seems to be needed is a methodology that would permit the study of
nursing meaning as it is being co-created in the lived experience of
the nursing situation. Supplemental methods could continue to include
traditional phenomenological and hermeneutic work with texts describing
particular nursing situations. Nurses who are interested in developing
knowledge of techniques or modes of expressing caring would continue to
use traditional methods of formal and human science for these kinds of
nursing-related questions.

The development of methods of nursing inquiry appropriate to the study
of the theory, Nursing as Caring, is in a formative stage. We understand
to a considerable extent the limitations of existing modes of inquiry,
and have a growing sense of what will be required of a new methodology.
Nursing scholars are working to develop methods to illuminate the
fullness of nursing. Examples of that work which has encouraged our
efforts include that by Parker (1993), Swanson-Kauffman (1986), Parse
(1990), and Ray (Wallace, 1992). The work of these scholars demonstrates
that the development of nursing ways of inquiry is important and that
a search has begun. As we have come to understand the concept of human
science, our understanding of nursing has been enriched. Like most
of our contemporaries in nursing, we were trained in the
often-unarticulated assumptions of natural science. And we have traveled
the road familiar to many nursing scholars, the road of expertise in
objectification and quantification. Along that road, we began to notice
the trivialization of cherished nursing ideas like presence, touch,
relationship, knowing, and caring. Resisting the temptation to abandon
the journey, we each persevered in a commitment to nursing as something
which mattered, something involving intimate, personal, caring
relationships. Discovering, inventing, and creating a new methodology
is an important dream and we are committed to continuing this aspect of
theory development.

Nursing as Caring is a transformational model for all arenas. Nursing
practice, nursing service organization, nursing education, and nursing
inquiry require a full understanding of nursing as nurturing persons
living caring and growing in caring, and these underlying assumptions:

  * 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 profession.

With these transformations, the fullness of nursing will be realized and
we will grow in our understanding of self and other as caring persons
connected in oneness.


REFERENCES

  Boeckh, P. (1988). Theory of criticism. In K. Mueller-Vollmer (Ed.), The hermeneutics reader. New York: Continuum.
  Droysen, J. (1988). The investigation of origins. In K. Mueller-Vollmer (Ed.). The hermeneutics reader. New York: Continuum, pp. 124-126.
  Gadamer, H. (1989). Truth and method. New York: Crossroad Publishers.
  Heidegger, M. (1988). Understanding and interpretation. In K. Mueller-Vollmer (Ed.), The hermeneutics reader. New York: Continuum, pp. 221-228.
  Macdonald, J. (1975). Curriculum and human interests. In W. Pinar, Curriculum theorizing: The reconceptualists. Berkeley: McCutchan Publishers.
  Oiler, C. (1986). Phenomenology: The method. In P. Munhall & C. Oiler (Eds.), Nursing research: A qualitative perspective. Norwalk, CT: Appleton-Century-Crofts.
  Parker, M. (1993). Living nursing values in nursing practice. Paper presented at 7th Annual Conference of the Southern Research Association, Birmingham, AL, February 18,1993.
  Parse, R. (1990). Parse's research methodology with an illustration of the lived experience of hope. Nursing Science Quarterly, 3,9-17.
  Ray, M.A. (1994). The richness of phenomenology: Philosophic, Theoretic and Methodologic Concerns. In J. Morse (Ed.), Critical issues in qualitative research. A contemporary dialogue. Newbury Park, CA: Sage, Ch. 7.
  Reeder, F. (1988). Hermeneutics. In B. Sarter (Ed.), Paths to Knowledge. New York: National League for Nursing.
  Swanson-Kauffman, K. (1986). A combined qualitative methodology for nursing research. Advances in Nursing Science, 8 (3), 58-69.
  Van Manen, M. (1990). Researching lived experience. London, Ontario: State University of New York Press.
  Wallace, C. (1992). A conspiracy of caring: The meaning of the client's experience of nursing as the promotion of well-being. Unpublished master's thesis, College of Nursing, Florida Atlantic University.
  Watson, J. (1988). Nursing: Human science and human care. A theory of nursing. New York: National League for Nursing.



[Illustration: Button]



EPILOGUE

The Theory of Nursing as Caring was initially presented in its entirety
at the South Florida Nursing Theories Conference in 1992. The theory
was explicated in the original release of Nursing as Caring: A Model for
Transforming Practice in 1993 (Boykin & Schoenhofer, 1993). As work has
progressed to develop the theory for use in nursing practice, research
and education, the underlying assumptions introduced in Chapter 1 have
been affirmed as central to the integrity of the theory. This epilogue
highlights ongoing development of the theory by its authors and by other
nurses. Developmental efforts include clarification of the concept of
personhood, expansion of the understanding of enhancing per-sonhood as
the general "outcome" of nursing, research innovations, and use of
the theory in middle range theory work and in the critical analysis of
caring.


CLARIFICATION OF THE CONCEPT OF PERSONHOOD

In Chapter 1, personhood was described as a process of living grounded
in caring. In an effort to clarify the meaning of "a process" in
the context of the theory of Nursing as Caring, we explained
that personhood, understood as living grounded in caring, is
processual--ongoing, experienced moment to moment, evolutionary,
transformative--rather than a generalized sequence of steps or
operations. In subsequent publications, personhood was described as
"living grounded in caring," eliminating the problematic use of the term
"process" entirely (Schoenhofer & Boykin, 1998a; Boykin & Schoenhofer,
2000).


RESEARCH DEVELOPMENT OF THE FOUNDATIONAL CONCEPTS OF PERSON AS CARING AND PERSONHOOD

Nursing as Caring guides nurses to enter into the world of the other
and allows them to come to know the nursed as living caring uniquely in
situation. In consulting with nurses using Nursing as Caring as their
framework for practice, we found that nurses could easily recognize
expressions of caring when caring was lived in ways familiar to their
own lifeworlds. However, in nursing situations where personal ways of
caring were outside the experience of the nurse, there seemed to be
difficulties in knowing and thus affirming the nursed as person uniquely
living caring in the moment. Without this situated knowing, we saw
that nurses tended to lose the focus of recognizing the other as living
caring uniquely in the moment, and instead, to concentrate on ways in
which persons "were not living caring" and "should grow in caring." This
tendency to return to a normative practice framework in difficult times
is easily understood as nurses struggle to transcend a familiar paradigm
characterized by terms such as "nursing process," "nursing diagnosis,"
"nursing intervention" and to evolve toward what has been called a
simultaneity paradigm (Parse, 1987).

Because knowing the other as caring is the basic act of nursing,
it became clear to us that knowledge expansion would be helpful in
enhancing nurses' ability to recognize uniquely personal ways their
patients live the value of caring. Schoenhofer conducted a series
of studies over several years to develop knowledge of personal lived
meaning of everyday caring. In one unpublished study, adolescents shared
stories of personal caring. Their stories were found to center around
the theme of "helping out." Adolescents described everyday caring in
terms such as "cheering up someone you love," "helping another get what
they need," "work as caring," "caring by physical presence." The stories
illustrated situations where caring was expressed as "helping out when
you don't really want to, but doing it anyway," "helping without being
asked," "filling in where caring is missing." One teenage boy told of
caring for a former girlfriend who was angry about their breakup; he
made deliberate efforts to remain active as a friend, as a way to
help the girl deal with the loss of their romantic relationship. He
characterized his caring as "keeping on showing care even though it
doesn't seem to change things."

In another similar study, 4th grade students told stories of caring in
which they acted as advocates for other children and offered help to
others, both adults and children, who were perceived as less fortunate
and in need of care (Schoenhofer, Bingham & Hutchins, 1998). Adults,
too, have unique and personal ways of living their everyday caring.
One father related an example of caring for his young daughter by
restricting her activities because of poor school performance, and
then engaging in a dialogue with her that resulted in a compromise. The
father saw willingness to discipline as an act of caring and felt that
his willingness to listen to the child's perspective was also part of
his caring (Schoenhofer, Bingham & Hutchins, 1998). Several adults whose
parents had become disabled told stories of caring for parents in ways
that preserved cherished role relationships. These adults understood
that their caring required extra effort to avoid infantalization of the
parent but felt that without that extra effort, attention would be given
to certain needs but adequate caring would not be given.

Research into everyday caring was conducted in a group discussion
format, with persons invited to relate a story that illustrated how they
lived their caring in everyday situations. The ease with which these
research participants understood what was being asked of them, their
willingness to respond and the clarity of the exemplars they shared have
the potential to inform nursing practice. When nurse colleagues learned
of this research effort, they often expressed doubt that people could
and would describe their everyday caring ways. Based on the experience
of the researchers and research participants in this series of studies,
however, it became clear that persons do understand their unique ways of
caring, and do recognize the importance of sharing that understanding.

Nurses committed to practice guided by the tenets of Nursing as Caring
can and should incorporate direct invitation as part of their coming to
know other as caring person, A number of important benefits are possible
with a direct approach to knowing the other as caring. One benefit is
that as the nurse raises the issue of caring, patients are helped
to understand that caring is of immediate importance to nurses,
thus clarifying the service and value of nursing among the health
disciplines. A second benefit is that as nurses address caring directly
with their patients, nurses themselves gain affirmation of nursing as
a caring service and of themselves as persons committed to caring.
However, the most immediate benefit of a direct approach to caring is
the opening of a line of communication that clearly establishes the
"caring between," that space, that relationship within which and
through which all that is important in nursing occurs. The patient is
given the opportunity to recognize self as caring person and to join
in mutual affirmation and celebration with the nurse. Nurses who are
reluctant to engage patients in dialogues about caring ways may think
the topic is "too intimate." It is true that caring is intimate and
personal, but caring is also very visible, just as many of the topics
introduced in the nursing situation are personal and intimate and have
visible referents. As nurses have the courage to raise the topic of
caring, the central importance of caring in human living can become not
only recognized but openly and publicly valued.


RESEARCH DEVELOPMENT OF NURSING OUTCOMES-VALUES EXPERIENCED IN THE NURSING SITUATION

Another research thread has focused on the development of an approach to
identifying and languaging outcomes of nursing guided by the theory of
Nursing as Caring (Boykin & Schoenhofer, 1997; Schoenhofer & Boykin,
1998a, 1998b). Within the context of the theory, the idea of outcomes
has been reconceptualized as "values experienced in the nursing
situation." Several case studies illuminated a dialogical form of praxis
involving nurse, patient and researcher that revealed values experienced
by patients and their nurses. Values experienced by families, health
care administrators and systems were also uncovered as the caring
created in the nursing situation was found to resonate beyond the
immediate nurse-patient relationship. This line of research has
demonstrated that while traditional economic valuation can be
calculated, the value of caring in nursing can and must be more clearly
explicated in human terms. For example, one case study of home health
nursing found that the economic value of six nursing visits produced a
health care cost savings of $5,709, primarily by obviating the necessity
of trips to the emergency department of the local hospital. Through
this unique research approach, the human value of the six visits was
identified and languaged in terms that clearly demonstrate the direct,
unmediated worth of nursing care--to the one nursed, the family, the
nurse and the larger circle of health care systems. The patient and
family gained the important value of confidence through the caring
of the home health nurse; with the nurse's commitment to caring,
they gained faith in themselves, their ability to deal with new
health-related situations as they arose, faith that they wouldn't be
left alone, faith that they were known as persons valuable in their
own right and worthy of care. This is the value of nursing, the reason
nursing exists as a distinguishable social and human service. Nurses
can learn to assert the human value of nursing, and in fact, nurses must
accept the responsibility for bringing the human value of care to the
forefront. Re-establishing the primary position of care in the health
care arena depends on nurses speaking out in clearly human terms about
the meaning and value of care, using the language of caring knowledgably
and without apology.

In May, 2000, Boykin launched a funded study to examine the potential
of the theory of Nursing as Caring to enhance the achievement of quality
outcomes in acute care settings. This two-year demonstration project and
evaluation study involves specifying quality indicators and targeting
benchmarks prior to introducing the theory as the nursing practice
framework in the acute care division of a community hospital. On-site
guidance and consultation in the use of the theory will be available
during the course of the project. Post-program evaluation will focus
on quality indicators and benchmarks relating to patient and staff
satisfaction, family and community support, and cost-benefit care
ratios.


THE THEORY OF NURSING AS CARING AS A CONCEPTUAL FRAME FOR MIDDLE-RANGE THEORIES

A theory that describes or explains a limited range of situations.
Locsin (1995) developed a model of the harmonious relation between
technology and caring in nursing. Further development of the model
led to a theory of technological competence as caring in critical care
nursing (Locsin, 1998). The mediating factors between application of
technology and caring in nursing are posited as intentionality and
authentic presence. The underlying theoretical framework draws on the
theory of Nursing as Caring, and particularly the focus of nursing as
knowing and thus nurturing the other as caring person. The intention to
know the other as caring person is actualized through direct knowing
as well as through the medium of technologically produced data. The
intention to care, to nurture the other as caring, is expressed in
interpersonal ways as well as in technological competence.

Dunphy (1998) drew on aspects of the theory of Nursing as Caring,
particularly the idea of knowing the other as caring person, in the
development of a model for advanced practice nursing, "the circle of
caring." Dunphy was concerned with clarifying the disciplinary identify
of advanced practice nursing as nursing. In an effort to transcend
perspectives of advanced practice nursing based on the traditional
reductionist medical science and nursing process models, processes of
care are superimposed on a traditional medical model (Dunphy, 1998). The
circle of care "incorporates individual strengths of both nursing and
medicine but reformulates them in a new model of care... rooted in the
lived experience of the patient" (p. 11). Caring quality indicators
suffuse the entire model, and include courage, authentic presence,
advocacy, knowing, commitment and patience. Elements formerly termed
diagnosis and treatment are termed caring processes in the new model,
in an attempt to ground advanced practice in nursing values. The core
component of the model, caring processes, focuses on ways of knowing the
person as caring and of truly being with the person in advanced practice
nursing situations. It is this core that provides the crucial link of
caring as the central focus of both traditional nursing and advanced
practice nursing.


CRITICAL ANALYSIS OF THE THEORY OF NURSING AS CARING

There is evidence that the theory of Nursing as Caring has entered the
mainstream of nursing thought. Nursing as Caring is included in several
collected and/or edited works on nursing theories (George, 1995; Parker,
1993; Parker, 2000). In George's (1995) compendium of general nursing
theories, Nursing as Caring is described and the structures of nursing
process and the metaparadigm concepts of Fawcett are used as a
framework for analysis and evaluation. Parker's books, Patterns of
Nursing Theories in Practice (1993) and Nursing Theories and Nursing
Practice (2000) are collections of original chapters authored by the
various nurse theorists and by nurses using the particular theory in
practice.

Nursing as Caring is represented in both these books by original
chapters authored by the theory's originators (Schoenhofer & Boykin,
1993; Boykin & Schoenhofer, 2000) as well as by chapters written by
nurses describing their practice which is guided by the theory (Kearney
&Yeager, 1993; Linden, 2000).

Nursing as Caring was one of four caring theories included in a
comparative analysis reported by McCance, McKenna and Boore (1999). That
analysis was based on a number of factors, including origin, scope
and key concepts of the theory, definition of caring, description of
nursing, the goal or outcome of nursing from the perspective of the
theory, and simplicity of the internal structure. Findings of the
analysis were developed in terms of utility of the theory in practice.
Smith (1999) analyzed concepts from the literature on caring in nursing
in an effort to uncover points of congruence between that literature and
the theoretical perspective of the Science of Unitary Human Beings.
The theory of Nursing as Caring figured prominently in Smith's concept
clarification, contributing to four of the five synthesized constitutive
meanings of caring: manifesting intentions, appreciating pattern,
attuning to dynamic flow and inviting creative emergence (Smith, 1999).


RESEARCH METHOD DEVELOPMENT

In Chapter 6, Theory Development and Research, we envisioned an
approach that "would include a phenomenological aspect which goes beyond
description to an hermeneutical process, within an action research
orientation" (Boykin & Schoenhofer, 1993, p. 97). Two research
approaches have been developed within the context of studying Nursing as
Caring, one focusing on discovering the lived meaning of everyday caring
and the second directed toward understanding the value experienced in
nursing situations.

There is relatively little literature that deliberately sets out to
describe the multitude of ways of human caring. However, most if not
all human text does reflect uniquely personal ways of caring, and
can profitably be studied for this purpose. In an effort to provide a
knowledge base of the variety of human caring ways, one of the authors
(Schoenhofer) innovated a group phenomenology approach in which research
participants not only generated data in group settings, but also led the
synthesis of meaning (Schoenhofer, Bingham, & Hutchins, 1997). The
group approach to data generation was chosen for several reasons--one
was efficiency, but the primary reason was a belief in the synergistic
potential of the group process experience. The group approach to data
synthesis was added to the design based on the assumption that persons
living the phenomenon being studied and generating the data may be most
well qualified to intuit meaning across examples. The series of studies
of everyday caring may best be understood as general foundational human
science, rather than as nursing science per se. Results of the studies
produced knowledge that has potential to enlighten nursing practice,
rather than producing direct knowledge of nursing practice.

While initiated for research purposes, the group phenomenology
approach became a form of nursing praxis. Early in the project,
groups spontaneously shared a sense of pleasure and gratitude for the
experience of celebrating themselves and each other as caring persons.
This opportunity for reflection was then added as closure for the
subsequent groups as it was recognized by the primary researchers that
the tenets of Nursing as Caring were being lived: persons were known,
acknowledged, affirmed and celebrated as caring; per-sonhood was
enhanced as group members recapitulated, clarified and reaffirmed
the meaning and value of caring in their lives; caring between nurse
(researchers) and nursed in the nursing (research) situation was created
and persons were nurtured in their uniquely personal ways of caring.

A second research approach was designed to study values experienced in
nursing situations (Schoenhofer & Boykin, 1998a; 1998b). The design of
this approach was based on several considerations: 1) the tenet that all
that can be known of nursing is known through the nursing situation, the
shared lived experience of caring between nurse and nursed; and, 2)
the blurred lines between research and practice, between roles of
researcher, practitioner and even patient. A mode of inquiry into
outcomes of caring in nursing, from the perspective of Nursing as
Caring, must necessarily be centered within the nursing situation. In
earlier phases of this research, only the nurse participated in the
research dialogue (Boykin & Schoenhofer, 1997). While this approach was
fruitful, two important qualities were missing: 1) the synergism that
brought a wealth of rich data when both nurse and nursed were present;
and, 2) the intersubjective confirmation provided by having both the
nurse and the nursed as research participants. Once again, the mutuality
of the dialogue about the value of caring experienced went beyond
simple data production for research purposes. The dialogue itself was an
extension of the nursing relationship and the caring between nurse and
nursed, with the research nurse now included in the unfolding nursing
situation.


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CONCLUSION

This epilogue has been written to bring the reader up to date on the
development of the theory of Nursing as Caring. Developmental efforts
projected in Chapter 6 are still needed, and efforts in progress hold
promise for further development. As the cadre of nurses interested in
working within the theory grows, development will accelerate, in both
projected and novel directions.

Anne Boykin, PhD, RN Professor and Dean College of Nursing Florida
Atlantic University

Boca Raton, Florida

October, 2000

Savina O. Schoenhofer, PhD, RN Professor of Graduate Nursing Alcorn
State University

Natchez, Mississippi


REFERENCES

  Boykin, A., & Schoenhofer, S. 0. (1993). Nursing as caring: A model for transforming practice. New York: National League for Nursing Press.
  Boykin, A., & Schoenhofer, S. 0. (2000). Nursing as caring: An overview of a general theory of nursing. In Parker. M. E., Ed., Nursing theories and nursing practice. Philadelphia: F. A. Davis Co.
  Boykin, A., & Schoenhofer, S. 0. (1997). Reframing nursing outcomes. Advanced Practice Nursing Quarterly, 1(3), 60-65.
  Dunphy, L. H. (1998). The circle of caring: A transformative model of advanced practice nursing. 20th Research Conference of the International Association for Human Caring, Philadelphia, Pa.
  George, J. B. (1995). Nursing theories: The base for nursing practice. (4th ed.). Norwalk: CT: Appleton & Lange.
  Kearney, C. & Yeager, V. (1993). Practical Applications of Nursing as Caring theory. In Parker, M. E., Ed. Patterns of nursing theories in practice. New York: National League for Nursing Press, Ch. 8.
  Linden, D. (2000). Application of Nursing as Caring in practice. In Parker, M. E., Ed., Nursing theories and nursing practice. Philadelphia: F. A. Davis Co., 1993.
  Locsin, R. C. (1995). Machine technologies and caring in nursing. Image, 27, 201-203.
  Locsin, R. C. (1998). Technological competence as caring in critical care nursing. Holistic Nursing Practice, 12(4), 50-56.
  McCance, T. V., McKenna, H. P., & Boore, J. R. P (1999). Caring: Theoretical perspectives of relevance to nursing. Journal of Advanced Nursing, 30, 1388-1395.
  Parker, M. E. (Ed.). (2000). Nursing theories and nursing practice. Philadelphia: F. A. Davis Co.
  Parker, M. E. (Ed.). (1993). Patterns of nursing theories in practice. New York: National League for Nursing.
  Parse, R. R. (1987). Nursing science: Major paradigms, theories and critiques. Philadelphia: Saunders.
  Schoenhofer, S. 0., Bingham, V., & Hutchins, G. C. (1998). Giving of oneself on an-other's behalf: The phenomenology of everyday caring. International Journal for Human Caring, 2(2), 23-29.
  Schoenhofer, S. 0., & Boykin, A. (1993). Nursing as Caring: Issues for practice. In
  Parker, M. E., (Ed). Patterns of Nursing Theories in Practice. New York: National League for Publications, pp. 83-92.
  Schoenhofer, S. 0., & Boykin, A. (1998a). The value of caring experienced in nursing. International Journal for Human Caring, 2(4), 9-15.
  Schoenhofer, S. 0., & Boykin, A. (1998b). Discovering the value of nursing in high tech environments: Outcomes revisited. Holistic Nursing Practice, 12(4), 31-39.
  Smith, M. C. (1999). Caring and the Science of Unitary Human Beings. Advances in Nursing Science, 21(4), 14-28.


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INDEX


  Adaptation Model (Roy), 15, 16 Administration, nursing education, 41, 48-50
  Administration, nursing service, 32-38 Advanced practice, 61
  Aesthetic knowing, 6, 9, 14, 20, 24, 46, 75, 77, 79, 91
  Aesthetic project, 46
  Allen, D.G.
  "Nursing research and social control: Alternative models of science that emphasize understanding and emancipation," 7
  "The social policy statement: A reappraisal," 7
  "The American Nurses' Association position statement on nursing and social policy: Philosophical and ethical dimensions" (Silva), 7
  American Nursing Association
  Nursing: A social policy statement, 7 Analysis and evaluation of conceptual models of nursing (Fawcett), 8
  Andrews, H.
  The Roy Adaptation Model: The definitive statement, 15-16
  "Application of nursing as caring in practice" (Linden), 62
  The Art of Administration (Tead), 32 Authentic presence, 3-4, 17-19, 25, 61 Avant, K.
  Strategies for theory construction in nursing, 8 "Ave Maria and Therapeutic touch for David" (Stobie), 46-47
  "The behavioral system model of nursing" Johnson), 15-16
  Benner, P.
  The primacy of caring: Stress and coping in health and illness, 35

  Bingham, V.
  "Giving of oneself on another's behalf:
  The phenomenology of everyday
  caring," 58, 62
  Boeckh, P.
  Theory of criticism, 52
  Bohm, D.
  "On dialogue," 35
  Boore, J. R. P.
  "Caring: Theoretical perspectives of
  relevance to nursing," 62
  Boykin, A.
  "Caring in nursing: Analysis of extant
  theory," 9, 19, 47-48
  "Creating a caring environment:
  Moral obligations in role of
  dean," 36
  "Discovering the value of nursing in
  high tech environments," 59, 63
  "Nursing as caring: Issues for practice,"
  62
  Nursing as caring: A model for transforming
  practice, 57, 62
  Nursing as caring: An overview of a general
  theory of nursing, 57, 62
  "Reframing nursing outcomes," 59, 63
  "Story as link between nursing
  practice, ontology, epistemology,"
  14, 17, 19, 20
  "The value of caring experienced in
  nursing," 57, 59, 63
  Brownell, J.
  The Curriculum and the Disciplines of
  Knowledge, xiv, 6
  Budget decisions, 34
  Calls for nursing, 13, 14, 15
  administrator, nursing, 32-35 dance of caring persons, 36-37 and education, nursing, 44, 4
  nursing situation, 17,18,21-22,33,34, 39-40
  study of, 53
  Caring and technology, 61
  "Caring and the science of unitary human beings" (Smith), 62
  Caring and advanced practice, 61 Caring theories compared, 62
  "Caring between" phenomenon, 14 "Caring for life and death: Nursing in a
  hospital-based hospice" (Samarel),
  27
  "Caring from a human science perspective" (Parse), 3
  "Caring in nursing: Analysis of extant theory" (Boykin & Schoenhofer), 9, 19,47-48
  "Caring in the instance of unexpected early pregnancy loss" (Swanson-Kauffman), 24
  Caring In the moment, 11
  Caring ingredients (Mayeroff), 4-5,23, 31,46,48
  Caring: The Human Mode of Being, Implications for Nursing (Roach), 2,19
  "Caring: Theoretical perspectives of relevance to nursing" (McCance, McKenna, and Boore), 62
  Carper, B.
  "Fundamental patterns of knowing in nursing," 8-9,11,42-45
  Carr, S.
  "Intensive care," 42-43,45
  Cassarrea, K.
  "Improving service through patient surveys in a multihospital organization," 35
  Chinn, P.
  Theory and Nursing, 8
  "The circle of caring: A transformatic model of advanced practice nursing" (Dunphy), 61
  "A combined qualitative methodology
  for nursing research" (Swanson-Kauffman), 24,55
  Concept Formalization in Nursing: Process and
  Product (Nursing Development Conference Group), 6,8
  "Connectedness: A concept for nursing" (Kronk), 28-30
  "Connections" (Maxwell), 20-21 Cooper, M.C.
  "Covenantal relationships: Grounding for the nursing ethic," 7
  Cost containment, 35
  Covenantal relationship, 7, 27
  "Covenantal relationships: Grounding for the nursing ethic" (Cooper), 7 "Creating a caring environment: Moral obligations in role of dean" (Boykin), 36
  "A critique of the ANA Social Policy
  Statement population and
  environment focused nursing" (White), 7
  "Curriculum and human interests" (Macdonald), 52
  The Curriculum and the Disciplines of
  Knowledge (King and Brownell), 6
  Dance of caring persons, 36-37 illus. 37
  and faculty selection, 48 and nursing education, 41-42,49 Deceased patient, 18,19
  "Deconstructing the dogma in nursing knowledge and practice: (Rodgers), 7 Deviant/evil patient, 18,19
  Dialogue, use of in education, 44-45 Difficult to care situation, 25
  "The dilemma of nursing: Current
  quandaries and lack of direction"

  (Packard and Polifroni), 7 Discipline, nursing as, 6-9
  and education, 54
  nursing situation, 18-19 and phenomenology, 53-54
  and theory development, 53-54 "Discovering the value of nursing in high tech environments" (Boykin and Schoenhofer), 59,63
  Droysen, J.

  "The investigation of origins," 52 Duffy, J.
  "The impact of nurse caring on patient outcomes," 35
  Dunphy, L. H.
  "The circle of caring: A transformatic model of advanced practice nursing," 61
  The Dynamic Nurse-Patient Relationship (Orlando), 27-28
  Education, nursing, 24,41-50 administration, 41,48-50 dance of caring persons, 41-42 dialogue, 44-45
  faculty selection, 48

  knowing, patterns of, 42-45 and nursing situation, 42
  Empathic paradigm, 5
  Empirical knowing, 9, 24, 42, 43, 45, 51 Essay examination, 46
  "The essential structure of a caring interaction: Doing phenomenology" (Riemen), 24
  Ethical knowing, 9, 24, 42, 44, 45, 51 everyday caring, 58, 59
  "Existential advocacy: Philosophical foundations of nursing" (Gadow), 3
  Faculty, selection of, 48
  Fawcett, T.
  Analysis and evaluation of conceptual models
  of nursing, 8
  Flexner, A.
  Medical education in the United States and
  Canada, 7
  "Fundamental patterns of knowing in
  nursing" (Carper), 9, 42-44
  Gadamer, H.
  Truth and Method, 52
  Gadow, S.
  "Existential advocacy: Philosophical foundations of nursing," 3
  "Touch and technology: Two
  paradigms of patient care," 5, 12, 28
  George, J. B.
  Nursing theories: The base for nursing practice, 61
  "Giving of oneself on another's behalf: The phenomenology of everyday caring" (Schoenhofer, Bingham, and Hutchins), 58, 62
  Guralnik, D.
  Webster's New World Dictionary of the American Language, 41
  "Healing-HIV+" (Wheeler), 32
  Health services discussion, nursing's contribution to, 30
  Heidegger, M.
  "Understanding and interpretation," 52
  Nelson's adaptation level theory, 28 Hermeneutic circle, 52, 55 "Hermeneutics" (Reeder), 52
  Hologram and view on relationships, 5 Home nursing, 28
  "Honestly" (Little), 25-27

  The Human Act of Caring (Roach), 2
  Human Care, theory of (Watson), 3 Human science, nursing as, 5, 8-9, 51-53 Humanistic Nursing (Paterson & Zderad), 34 Hutchins, G. C.
  "Giving of oneself on another's behalf: The phenomenology of everyday caring," 58, 62
  "The impact of nurse caring on patient outcomes" (Duffy), 35
  "Improving service through patient surveys in a multihospital organization" (Cassarrea, Mills, & Plant), 35
  "Intensive Care" (Carr), 42-43, 45 intentionality, 61
  "The investigation of origins" (Droysen), 52
  Jacobs, M.
  Theory and Nursing, 8
  Johnson, D.E.
  "The behavioral system model of
  nursing", 15, 16
  Journaling, 46
  Kearney, C.
  "Practical applications of nursing as
  caring theory," 62
  King, A., ix
  The Curriculum and the Disciplines of
  Knowledge, 6
  Knowing
  aesthetic, 6, 9, 14, 20, 24, 51
  as caring ingredient, 58-59, 8081
  empirical, 9, 24, 42, 43, 45, 51
  four patterns of, 9, 24, 42-44
  personal, 9, 23-25, 37-38, 42-43,
  45-46, 51
  Knowlden, V.
  "The meaning of caring in the nursing
  role," 24
  Knowledge, nursing, 17, 20, 54-55, 96-97
  Kronk, P.
  "Connectedness: A Concept for
  Nursing," 28-30
  Languages of the Brain: Experimental

  Paradoxes and Principles (Pibram), 5 "Last rights" (Yelland-Marino), 34 Leininger, M.M., xiv
  "Leininger's theory of nursing: Cultural care diversity and universality," 15

  68 Index

  Little, D.
  "Honesty," 25-27
  Linden, D.
  "Application of nursing as caring in practice," 62
  Living caring, 1-2,11-13,23,25,30,42, 45
  "Living nursing values in nursing practice" (Parker), 55
  Locsin, R. C.
  "Machine technologies and caring in nursing," 61
  "Technological competence as caring in critical care nursing," 61 "Love, beauty and truth: Fundamental nursing values" (Schoenhofer), 20
  Macdonald, J.
  "Curriculum and human interests," 52
  "Machine technologies and caring in
  nursing" (Locsin), 61
  Maxwell, G.
  "Connections," 20-21
  Mayeroff, M., ix
  On Caring, 2-3,4-5,23,31,46,48
  McCance, T. V.
  "Caring: Theoretical perspectives of
  relevance to nursing," 62
  McKenna, H. P.
  "Caring: Theoretical perspectives of
  relevance to nursing," 62
  "The meaning of caring in the nursing
  role" (Knowlden), 24
  The Meaning of Persons (Tournier), 35
  Medical Education in the United States and
  Canada (Flexner), 7
  Meleis, A.
  Theoretical Nursing: Development and
  Progress, 15
  Mentally disabled child, 19
  Middle range theory, 60-61
  Mills, J.
  "Improving service through patient
  surveys in a multihospital
  organization," 35
  Neuman, B.
  The Neuman Systems Model, 16 "Noncaring and caring in the clinical setting: Patient's descriptions" (Riemen), 24
  Nurse administrator, 32-35
  budget decisions, 34

  and calls for nursing, 33,38
  nursing situation, 34-35

  relationship to direct care, 32-33 Nursed as caring person, 12
  Nursing as caring: A model for transforming practice (Boykin and Schoenhofer), 57,62
  Nursing as caring: An overview of a general theory of nursing (Boykin and Schoenhofer), 57,62
  "Nursing as caring: Issues for practice"

  (Boykin and Schoenhofer), 62 Nursing: A Social Policy Statement (American
  Nurses Association), 7
  Nursing as Caring
  as stabilizer of organization, 35-36 discipline and profession, nursing as, 6-9
  educational program grounded in, 46 ideas related to, 1-9 ideologies/cognitive frameworks not congruent with, 27
  nurse administrator decisions, 35 persons as caring, perspective of, 1-5
  transformational model, 55
  theory, ix-x, 11-16
  Nursing Development Conference Group, ix
  Concept Formalization in Nursing: Process and Product, 6-8
  Nursing Diagnosis movement, 27-28,30, 31
  Nursing: Human Science and Human Care. A Theory of Nursing (Watson), 3,15,52
  "Nursing on the caring edge; Metaphorical vignettes" (Watson), 19
  "Nursing Process" (Orlando), 27-28,30
  "Nursing research and social control: Alternative models of science that emphasize understanding and emancipation (Allen), 7
  "Nursing science, major paradigms, theories and critiques" (Parse), 58 Nursing situation, 8-9,12,13-16,46 and administration, nursing, 34-35 education, nursing, 42-45
  persons with altered levels of

  consciousness, 18-19 re-presentation of via art forms, 20 shared lived experience, 18,20-22,25,
  30

  study of, 44-45
  theory development, 53
  Nursing theories: The base for nursing practice
  (George), 61
  "Nursing theories and nursing practice
  (Parker), 61
  Oiler, C.
  "Phenomenology: The method," 53 On Caring (Mayeroff), 2-3, 4-5, 23, 31, 46, 48
  "On dialogue" (Bohm), 35
  Orem, D.E.
  Nursing: Concepts of Practice, 15, 16 Self-Care Deficit Theory of Nursing, 15, 16
  Organization
  hierarchical model of, 36-37

  stabilizer, Nursing as Caring as, 35-36 Orlando, L
  The Dynamic Nurse-Patient Relationship, 27-28

  Nursing Process approach, 27-28, 30 Outcomes of caring, 59-60
  Packard, S.A.
  "The dilemma of nursing science: Current quandaries and lack of direction," 7
  Parenthood, nursing profession as, 15 Parker, M.
  "Living nursing values in nursing practice," 55

  Nursing theories and nursing practice, 61 Patterns of nursing theories in practice, 61 Parse, R.
  "Caring from a human science perspective," 3
  "Nursing science, major paradigms, theories and critiques," 58 "Parse's research methodology with an illustration of the lived experience of hope", 55
  Parson's theory of Social System Analysis, 15
  Paterson, J., ix
  Humanistic Nursing, 34
  Patient satisfaction, 35
  Patterns of nursing theories in practice (Parker), 61
  Person as caring, 1-5, 11-13, 17, 19-20 discipline and profession, nursing as, 11-12

  Person as complete/whole, 5, 12-13 Personal knowing, 6, 9, 14, 23-25 Personhood, 4, 9, 11, 13, 14, 17, 57 Phenix, P., ix

  Realms of Meaning, 6, 18, 20, 22 Phenomenology, 53-55
  Phenomenology: The Method (Oiler), 53 Philanthropic paradigm, 3, 5, 12, 28 Plant, M.
  "Improving service through patient surveys in a multihospital organization," 35
  Polifroni, E.C.
  "The dilemma of nursing science: Current quandaries and lack of direction," 7
  Post-anesthesia patient, 19
  Postmortem care, 18, 19
  "Practical applications of nursing as caring theory" (Kearney and Yeager), 62
  Practice of nursing, 23-32 communicating caring in, 24 and interface with health care system, 31
  Pribram, K.H.
  Languages of the Brain: Experimental Paradoxes and Principles, in Neuropsychology, 5
  The Primacy of Caring: Stress and Coping in Health and Illness (Benner & Wrubel), 25
  Problem Oriented Medical Records, 27 Processual, nursing as, 30
  Profession, nursing as, 6-9, 11-13, 15, 19, 54
  as caring, 30-31
  contribution to health policy planning, 30-31
  covenantal relationships, 7 and nursing inquiry, 53
  social contract, 7
  Ray, M.A., xiv
  "The richness of phenomenology:
  Phenomenologic-hermeneutic
  approaches," ix, 52, 55
  Realms of Meaning (Phenix), 6
  Reason and Commitment (Trigg), 3
  Reeder, E
  "Hermeneutics," 52
  "Reframing nursing outcomes,"
  (Boykin and Schoenhofer), 59, 63

  70 Index

  Re-presentation of nursing situation, 20 Research methods, 62-63
  Researching Lived Experience (Van Manen), 52, 53
  "The richness of phenomenology:
  Phenomenologic-hermeneutic approaches" (Ray), 52
  Riemen, D.
  "The essential structure of a caring interaction: doing phenomenology," 24
  "Noncaring an caring in the clinical setting: Patients' descriptions," 24 Roach, S., ix
  Caring: The Human Mode of Being,
  Implications for Nursing, 2, 19
  The Human Act of Caring, 2
  Rodgers, B.L.
  "Deconstructing the dogma in nursing knowledge and practice," 7 Roy Adaptation Model, 15
  Roy, C.
  The Roy Adaptation Model: The Definitive Statement, 15, 16
  Samarel, N.
  "Caring for life and death: Nursing in a

  hospital-based hospice," 27 Schoenhofer, S.
  "Caring in nursing: Analysis of extant theory," 9, 19, 47-48
  "Discovering the value of nursing in high tech environments," 59, 63
  "Giving of oneself on another's behalf: The phenomenology of everyday caring," 58, 62
  "Love, beauty and truth: Fundamental nursing values," 20
  "Nursing as caring; Issues for practice," 62
  Nursing as caring: A model for transforming practice, 57, 62
  Nursing as caring: An overview of a general theory of nursing, 57, 62
  "Reframing nursing outcomes," 59, 63 research data, unpublished, 27 "Story as link between nursing
  practice, ontology, epistemology,"
  14, 17, 19, 20
  "The value of caring experienced in nursing," 57, 59, 63
  Science, movement toward, 24
  Self as caring person, 3-4, 12-13, 17, 19, 25, 27

  Self-Care Deficit Theory of Nursing (Orem), 15, 16
  Shared lived experience, 20-22
  Silva, M.C.
  "The American Nurses' Association position statement on nursing, and social policy: Philosophical and ethical dimensions," 7
  Smith, M. C.
  "Caring and the science of unitary human beings," 62
  Social contract, 6, 7
  "The social policy statement: A reappraisal" (Allen), 7
  Stobie, M.
  "Ave Maria and Therapeutic Touch for David," 46-47
  "Story as link between nursing practice, ontology, epistemology" (Boykin & Schoenhofer), 14, 17, 19, 20
  Story, use of, 45
  difference from nursing case report, 31 in education, 45, 49
  Strategies for Theory Construction in Nursing (Walker & Avant), 8 Swanson-Kauffman, K.
  "A combined qualitative methodology
  for nursing research," 24, 55
  "Caring in the instance of unexpected
  early pregnancy loss," 24
  Tead, 0.
  The Art of Administration, 32 "Technological competence as caring in critical care nursing" (Locsin), 61 Technology, 61
  Technology movement, 24
  Theoretical Nursing: Development and Progress (Meleis), 15
  Theory and Nursing (Chinn and Jacobs), 8 Theory development and research, Nursing as Caring, vii--viii, 51-55 levels of, 8
  middle range, 60-61
  model development, history of, 15

  phenomenology orientation, 53 "Theory of criticism" (Boeckh), 52 Theory of Nursing as Caring, 11-16 Time allocation, 34-35
  "Touch and technology: Two paradigms of patient care" (Gadow), 5, 12, 28
  Tournier, P.
  The Meaning of Persons, 35

  Trigg, R.
  Reason and Commitment, 3
  Truth and Method (Gadamer), 52
  Unconscious patient, 18, 19 "Understanding and interpretation" (Heidegger), 52
  "Untraining" of nurses, 23-24
  "Value of caring experienced in nursing, the" (Boykin and Schoenhofer), 57, 59, 63
  Van Manen, M.
  Researching Lived Experience, 52, 53 von Bertalanffy's general systems theory, 15
  Walker, L.
  Strategies for Theory Construction in Nursing, 8
  Watson, J., ix
  Nursing: Human science and Human Care.

  A Theory of Nursing, 3, 15, 52 "Nursing on the caring edge:
  Metaphorical vignettes," 19

  Webster's New World Dictionary of the

  American Language (Guralnik), 41 Wheeler, L.
  "Healing-H1V+ ," 32
  White, C.M.
  "A critique of the ANA Social Policy Statement ... population and environment focused nursing," 7 Winland-Brown, J.
  unpublished research data, 27 Wrubel, J.
  The Primacy of Caring: Stress and Coping in Health and Illness, 35
  Yeager, V.
  "Practical applications of nursing as caring theory," 62
  Yelland-Marino, T. "Last Rights," 34
  Zderad, L., ix
  Humanistic Nursing, 34


NURSING AS CARING

A MODEL FOR TRANSFORMING PRACTICE

Anne Boykin,

Savinan O. Schoenhofer

Caring is one of the first words that comes to mind when talking about
the practice of nursing. Caring is an essential value in the personal
and professional lives of nurses. However, the formal recognition of
caring in nursing as an area of study is relatively new. Nursing As
Caring sets forth a different order of nursing theory.

This new nursing theory is personal, not abstract. The focus of the
Nursing As Caring theory is not toward an end product such as health or
wellness; it is about a unique way of nurses 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. This
is perhaps the most basic, bedrock, and therefore radical, of nursing
theories and is essential to all that is truly nursing.


EXPERIENCE





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Established in 1988, ISYS Search Software is a global supplier of enterprise
search solutions for business and government.  The company's award-winning
software suite offers a broad range of search, navigation and discovery
solutions for desktop search, intranet search, SharePoint search and embedded
search applications.  ISYS has been deployed by thousands of organizations
operating in a variety of industries, including government, legal, law
enforcement, financial services, healthcare and recruitment.



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