Reflection And Learning Provide one specific example of how you achieved the weekly objectives. What personal values, if any, were challenged this week?
What values can you reaffirm or want to reconsider after this learning?
Write 1-2 paragraphs reflecting on caring and culture in the NP role. Chapter 22: Theories Focused on Caring
Joanne R. Duffy
Caring is an evolving human science ( Watson, 2012 ), a relational process ( Duffy, 2013 ), a “nurturing way to relate to a valued other” ( Swanson, 2016 ), and a way of being human ( Roach, 1987 ) that enhances personhood ( Boykin & Schoenhofer, 2001a ). According to Duffy (2009 , 2013 ), when practiced authentically, caring relationships lead to feeling “cared for,” an antecedent to optimal patient, nurse, and system outcomes. It has been the subject of much focus in nursing for the last 30 years, having formerly been described as the “moral ideal of nursing” ( Watson, 1985 , p. 29) and used by many to guide research, design measurement tools, lead, educate, and practice professional nursing. Some have contended that caring is the essence of nursing ( Leininger, 1984 ; Watson, 1979 , 1985 ), while others have asserted that caring is not solely the purview of nursing ( Boykin & Schoenhofer, 2015 ). Within the disciplinary interpretation of nursing, however, caring has been a central tenet not only for theorists, but also for students and nursing educators, and is deeply reflected in the American Nurses Association’s Code for Nurses With Interpretive Statements ( Boykin & Schoenhofer, 2015 ). Duffy (2013) contends that in the larger context of healthcare systems, when relationships among patients, families, nurses, and the entire healthcare team are of a caring nature, intermediate consequences occur, enabling forward progress or advancement.
Caring is a universal phenomenon that occurs in all societies and cultures ( Leininger, 1978 , 1991 ). In fact, Watson (2012) views human caring as a process that is “connected to universal human struggles and human tasks” (p. x). It is manifested most noticeably in many families. For example, in the parent–child relationship, parents can be observed delivering physical, emotional, and educative actions that enhance safety, promote physical growth, and encourage emotional and cognitive development in their children. According to Mayerhoff (1970), caring is essential for the attainment of such human goals. Thus, caring relationships are transforming in that they facilitate human change, growth, and forward movement, adding significantly to the evolution of human life. In the parent–child relationship, parental caring actions are founded on a loving bond or connection between parent and child that assumes expanded potentials and future advancement in the children. In the patient–nurse relationship, caring actions are founded on disciplinary values and the use of relational strategies that provide the context for specific nursing interventions that ultimately engender advancement (in terms of improving health outcomes) in recipients.
In the context of health care, the vulnerability of persons of all ages and backgrounds creates an unusual dependency on healthcare providers (in this case, professional nurses) for behaviors, skills, and attitudes that help protect patients from harm, enable the delivery of high-quality services, preserve human dignity, instill confidence, enable participation in care processes and decisions, promote comfort, uphold hope, and advance general well-being. As patients and families try to negotiate the complex healthcare system and discover the meaning of their illness experience, professional nurses who cultivate and sustain caring relationships with them enable the positive emotion of feeling cared for ( Duffy, 2013 ). It is this optimistic emotion that often energizes patients and families to participate, learn, follow through, interact, and persist in meeting their health goals. Furthermore, nurses also benefit from caring relationships with patients and families in that such relationships provide the needed feedback about the important work they do, affording meaning that may, in fact, facilitate increased work satisfaction. Caring in this instance is not viewed as simply kind words or courteous acts, but rather a cohesive blending of disciplinary values, knowledge-based actions, skilled approaches, and affirmative attitudes that, taken together, guide the human-to-human patient–provider relationship. It is within this caring relationship that the uniqueness of the patient becomes known to the nurse and the meaning of the illness experience can be fully appreciated by the patient. Caring relationships, therefore, are the medium for healthcare decisions, interventions, and, ultimately, healing and health.
Since caring, along with its explicit knowledge, specialized skills, and attitudes, provides the conduit for healthcare delivery, health services grounded in caring are vital in the delivery of safe, high-quality services. Such services are the basis for ongoing interactions, accurate gathering and reporting of pertinent assessment data, establishment of relevant diagnoses, provision of effective interventions, and continuous improvement. Numerous frameworks have advanced the knowledge of how caring contributes to health and healing (for both the care provider and the care recipient). To better appreciate the phenomenon of caring, four theories are presented in this chapter: (1) the Nursing as Caring Theory, (2) the Theory of Human Caring Science, (3) the Theory of Caring and Healing, and (4) the Quality–Caring Model.
THE NURSING AS CARING THEORY (ANNE BOYKIN AND SAVINA SCHOENHOFER)
The Nursing as Caring Theory is considered a grand theory ( Boykin & Schoenhofer, 1993 ) and was heavily influenced by Mayerhoff’s (1970) and Gaut’s (1984) philosophical and theoretical discussions of caring, Roach’s (1987) five C’s (compassion, competence, confidence, conscience, and commitment), and Paterson and Zderad’s (1988) humanistic views of nursing. While considering the curricular infrastructure at Florida Atlantic University, Boykin and Schoenhofer (1990 , 1993 ) carefully analyzed existing work on caring using an organizing framework that helped identify common themes and unique stances among several caring scholars. Their resulting theory was intended to be a practice theory that honors the special nature of all persons as caring. The central assumption of the theory—that all persons are caring by virtue of their humanness—underlies its major concepts: personhood, the nursing situation, calls for nursing, and nursing as caring.
Personhood is “a process of living grounded in caring” (Schoenhofer & Boykin, 1993, p. 83) and is enhanced in “nurturing relationships with caring others” (p. 83). The nursing situation is the lived experience between a patient and a nurse that affects one’s personhood. Each nursing situation is unique and dynamic. In this situation, the nurse brings his or her caring self and comes to know the other person as a caring human. In this nursing situation, calls for nursing that request specific forms of caring can be heard by the nurse. As the nurse responds to these calls, the other’s unique experience and personal growth can be enhanced. In this theory, the focus of nursing is living caring and growing in caring. As such, caring is the body of knowledge from which professional nurses uniquely respond through specific expressions of caring nurturance ( Boykin & Schoenhofer, 2015 ). Finally, intentionality of the nurse, defined as “consistently choosing personhood as a way of life and the aim of nursing” (Schoenhofer, 2002, p. 39), generates commitment and fuels resulting nursing actions.
The major assumptions of the Nursing as Caring Theory are summarized here:
· Persons are caring by virtue of their humanness.
· Persons are caring from moment to moment.
· Persons are whole or complete in the moment.
· Personhood is a way of living grounded in caring.
· Personhood is enhanced through participating in nurturing relationships with caring others.
· Nursing is both a discipline and a profession. ( Boykin & Schoenhofer, 2015 )
Boykin and Schoenhofer (2015) do not view caring as the unique province of nursing, but rather as a central value that focuses the profession. Boykin, Schoenhofer, Smith, St. Jean, and Aleman’s (2003) view of all persons as whole or complete just as they are does not incorporate the nursing process because it assumes some modification or change in persons is needed. Rather, these authors see nursing as “coming to know persons as caring” (Aleman, 2003, p. 224) and creating caring responses that advance personhood. They view nursing as both a discipline and a profession, with practice guided by the theory entailing intention, formal study, and reflection on experience. The use of storytelling of the nursing situation as a form of evidence of nursing as caring as well as other methodologies, such as interpretive phenomenology, have characterized their approach to the study of caring (Schoenhofer, 2002).
The Nursing as Caring Theory has been applied both in curricular design and in various implementation and research projects. For example, Boykin, Schoenhofer, Smith, Jean, & Aleman (2003) , together with hospital-based investigators, reported the results of a project in which an 18-bed telemetry unit in a 350-bed for-profit hospital implemented the theory. Through the use of dialogue and specific practice strategies, patient and nurse satisfaction in this unit improved. A lesson learned through this project included that returning to fundamental nursing values created transformation. Another innovative application of the theory is detailed by Bulfin (2005). A partnership between a university (Florida Atlantic University) and a community hospital (Boca Raton Community Hospital) used the Nursing as Caring Theory to frame a professional practice model. Through four phases (education, understanding self, storytelling, and specific practice strategies), the model was evaluated using pre- and postintervention patient satisfaction measures. Postsatisfaction scores improved, although significance testing was not described. Qualitative approaches, such as patient letters, were also used in the evaluation of the project.
Another acute care unit project was evaluated after implementation of the Nursing as Caring Theory ( Dyess, Boykin, & Bulfin, 2013 ). In this participatory action project, nurses clearly expressed a commitment to caring. In a systems implementation of the model ( Pross, Hilton, Boykin, & Thomas, 2011 ), the process of transforming ways of relating was described as an important foundation for sustained change. Likewise, integrating caring theory into education and practice was explained through an academic service partnership where faculty members, staff, and students were exposed to and expected to practice caring together ( Dyess, Boykin, & Riggs, 2010 ). Thus, the Nursing as Caring Theory has been applied by nurses, nurse educators, and nurse leaders in a variety of settings. The authors’ most recent text, Health Care System Transformation for Nursing and Health Care Leaders: Implementing a Culture of Caring ( Boykin, Schoenhofer, & Valentine, 2014 ), challenges current health system practices and offers a person-centered, caring framework upon which to transform health care.
Although progress is being made in terms of showcasing Nursing as Caring practice and gathering evidence related to the value of the theory, more systematic evaluation of its benefits to both patients and nurses is warranted. Future research using multiple methods will aid in this effort. For example, specific qualitative methods might elicit richer descriptions of caring situations and their consequences from both nurses’ and patients’ perspectives. Descriptive studies examining relationships between patients who receive nursing care on the basis of the theory and nursing-sensitive outcomes are needed as well. Finally, developing and testing specific nursing interventions grounded in the theory in varying populations would provide further validation.
THE THEORY OF HUMAN CARING SCIENCE (JEAN WATSON)
From a strong foundation in educational counseling and psychology, Jean Watson first developed the Theory of Human Caring while designing an integrated baccalaureate curriculum in a large school of nursing ( Watson, 1979 ). Watson’s goal was to present nursing as a distinct entity, a profession, a discipline and science in its own right, separate from, but complementary to, medicine.
The Theory of Human Caring was more formally articulated in 1985, when Watson authored the book Nursing: Human Science and Human Care. In this text, Watson elaborated on the caring occasion, the transpersonal nature of caring, the 10 carative factors, phenomenal fields, the influence of time (past, present, and future), and human growth—all of which are major concepts in the theory. In this theory, all persons are considered to be unique and to have a life history, social norms, and experiences that generate a subjective reality or phenomenal field. A caring occasion occurs whenever the nurse and another person come together with their unique subjective realities, seeking to connect to each other in the present. During this moment, with the carative factors authentically present, the interaction is considered to be transpersonal (unified body, mind, and spirit; collective consciousness; one with the universe). This transpersonal caring relationship conveys deep connections to the spirit of another that transcend time, space, and physicality, ultimately affecting the consciousness field as a whole, generating endless possibilities, facilitating human growth, learning, and development. Thus, both the care provider and the one being cared for evolve from the encounter ( Watson, 1985 ).
Later, more spiritual and energy-related aspects of caring were incorporated in the theory, with heightened awareness of the nurse’s intentionality and own personal evolution ( Watson, 1999 ). Likewise, a more sacred dimension of nursing’s work with a philosophical–ethical–moral dimension was presented in Watson’s (2006) book Caring Science as Sacred Science. Moreover, Watson has showcased her evolving views on caring resulting from personal experiences, fresh perspectives on the convergence of transpersonal caring and unitary science theories ( Watson & Smith, 2002 ), and metaphysical orientations. In doing so, Watson has suggested that caring is a foundational framework of caring–healing professions and laid the groundwork for a revised edition of her first book, Nursing: The Philosophy and Science of Caring, Revised Edition ( Watson, 2008 ). In this revised text, Watson first presents caritas nursing as the more mature perspective of nursing and transitioned the 10 carative factors to 10 caritas processes.
In 2012, Watson authored Human Caring Science: A Theory of Nursing. This text includes a more expanded worldview of universal cosmology (human connectedness) that affirms human caring science as the “disciplinary foundation for the nursing profession” ( Watson, 2012 , p. xi). It showcases a more unitary-transformative grand theory of evolving consciousness that includes a global worldview of connectedness to all. In this revision Watson clarifies the 10 caritas processes.
Caritas comes from the Greek word meaning “to cherish”; it connotes something that is very precious. Watson’s evolving path to this way of thinking highlights the connections between caring, spirituality, and human love. The connectedness of caring and love allows for deeper transpersonal and healing relationships, enriching for both the patient and the nurse ( Watson, 2015 ). Working within this expanded caring consciousness allows deeper connections between the human condition and universal love. Related to this evolving theoretical stance on caring, Watson (2015) posits that this direction becomes a “converging paradigm for nursing’s future” (p. 325).
A major concept in this evolved theory is the caritas field, which is described as a conscious healing presence founded on caring and love that profoundly changes the relational experience for nurses and patients alike ( Watson, 2012 ). Thus, the more evolved clinical caritas processes reflect spirituality and love for others.
The evolution of Watson’s Theory of Human Caring Science is a valuable example of the practical side of theory development. Changing worldviews, new insights and experiences, and emerging evidence provided the background for new or revised concepts and relationships over the course of the theory’s development. In an effort to expand the study of caring, Watson collated and critiqued 22 instruments for assessing and measuring the concept ( Watson, 2003 , 2009 ) and participated in the development of the Watson Caritas Patient Score ( Brewer & Watson, 2015 ). Many of these instruments have been subsequently used to evaluate how nurses and patients perceive caring, how caring relates to other health concepts (e.g., patient experiences), nurses’ perspectives of manager caring, caring in nursing education, and multisite benchmarking studies.
Numerous health systems have incorporated the theory into their professional practice models as they prepare for Magnet recognition. For example, using Watson’s model as the foundation, some health systems have integrated the theory into various patient care delivery systems ( Watson & Foster, 2003 ), while others have demonstrated their commitment to the theory through documentation systems ( Rosenberg, 2006 ), creating healing spaces for nurse time-outs, instilling centering practices into nursing workflow, and performing caring-based rounds ( Watson, 2015 ). Furthermore, schools of nursing have used the model for curricular planning, teaching–learning strategies, and course content ( Beck, 2001 ; Cook & Cullen, 2003 ), while others have studied caring within a broader educational context (Sitzman, 2015, 2016 ). Some have tested interventions on the basis of the caring theory or used the theory as the study’s conceptual foundation ( Arslan-Özkan, Okumus¸, & Buldukoǧlu, 2014 ; Erci, 2003; Smith, Kemp, Hemphill, & Vojir, 2002 ; Suliman, Welman, Thomas, & Omer, 2009 ), albeit the Theory of Human Caring Science as it was originally conceptualized. According to Watson (2006) , research in caring embraces inquiries that are both reflective and subjective, as well as objective–empirical.
Watson’s Theory of Human Caring Science has played a major role in helping professional nurses honor their unique and distinct values and has influenced the scholarship of countless others, including the theorists reviewed in this chapter. Boyd (2008) contended that the theory is especially useful for those with mental illness (p. 71); however, Frisch and Frisch (2011) cautioned that some patients (on the basis of their illness) may not easily enter this form of mutuality. The theory, with its current “caritas consciousness” concept, represents an authenticity of person that transcends the biomedical and bureaucratic nature of most health systems, sometimes presenting practical challenges for nurses’ work in the acute care environments. That being said, many U.S. acute care hospitals have embraced Watson’s theory as a component of their professional practice models!
In 2007, Watson established the Watson Caring Science Institute, a nonprofit that was recently transitioned to the University of Colorado as the Watson Caring Science Center ( University of Colorado, n.d. ). In this newly developed center, human caring knowledge, ethics, and clinical practice are advanced through educational programs (including a focused caring science PhD track), partnerships, research, and international collaboration. Watson has made extraordinary contributions to the discipline of nursing over the last four decades and continues her work guiding health professionals in this transforming and evolving human caring science. Ongoing evaluation of the theory in terms of its measurement, authentic application, and potential value to patients, families, health professionals, and the larger health system are warranted.
THE THEORY OF CARING AND HEALING (KRISTEN SWANSON)
Kristen Swanson’s middle-range theory of caring was developed through inductive methods while studying three groups of women. In this theory, caring is defined as “a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” ( Swanson, 1991 , p. 162). Using data from women who miscarried, neonatal intensive care unit caregivers (both parents and professionals), and at-risk mothers, five caring processes—maintaining belief, knowing, being with, doing for, and enabling—were described. Swanson maintains that while caring is not unique to nursing, it informs those relationships central to nursing.
Maintaining belief demonstrates faith in the capacity of others and provides nurses with the foundation for the commitment to serve (both society in general and individual patients). Knowing refers to understanding how others’ lives have meaning; it avoids assumptions and focuses on the one being cared for in order to better comprehend the client’s lived reality. Being with incorporates emotional presence. It conveys to clients that they matter and assures them that their reality is appreciated. It includes physical presence as well as ongoing availability. Doing for involves nursing behaviors that preserve another’s wholeness. It includes comforting, anticipating, protecting, maintaining confidentiality and dignity, interpersonal listening, teaching, coaching, referring, supporting and guiding, providing feedback, and validating the other’s reality. Enabling implies facilitating another’s capacity through providing information, being present and sharing, and assisting behaviors.
In 1993, Swanson structured these processes such that they were ordered to influence the intended outcome—namely, client well-being. Later, Swanson completed a meta-analysis of the state of caring research. In this review, although 130 empirical studies were identified, 18 of those provided evidence of the consequences of caring and noncaring both for nurses and for patients. More importantly, she highlighted the clear significance of caring knowledge to current nursing practice and identified its implications for the nursing practice of the future ( Swanson, 1999 ).
Using knowledge of caring and the inductively developed theory of caring, Swanson set out on a program of research that focused on responses to miscarriage and interventions to promote healing subsequent to early pregnancy loss. After completion of the meta-analysis, Swanson tested an intervention in a study of 242 women who had miscarried ( Swanson, 1999 ). Using a caring-based counseling intervention, she conducted a randomized trial with a Solomon four-group design to test the intervention on several outcomes. Findings revealed that the caring intervention had a positive effect on disturbed mood, anger, and level of depression. In addition, a majority of the patients reported satisfaction with the caring intervention. Monitoring caring as delivered in the miscarriage study involved both qualitative and quantitative (including the development of the Caring Professional Scale [ Swanson, 2002 ]) methods. Items on this instrument were derived from the five caring processes, and preliminary psychometric properties were evaluated.
A follow-up intervention-focused study using 341 couples compared three types of couples-focused interventions to no treatment, with the goal being to identify strategies to help men and women resolve depression and grief during the first year after a miscarriage ( Swanson, Chen, Graham, Wojnar, & Petras, 2009 ). Through this rigorous experimental design, findings revealed that overall, while participation in any of the three intervention arms accelerated women’s grief resolution, their resolution of depression was best enhanced by the three nurse-led and caring-based counseling sessions. Women who received three nurse counseling sessions were three to eight times more likely to see a faster decline in their symptoms of depression than were women who received similar but limited help or no such help.
Despite the limitations imposed by the predominantly White and heterosexual samples, Swanson was able to demonstrate the benefits of caring interventions in terms of decreased depression, improved mood, decreased anger, and intervention satisfaction for persons who had experienced a pregnancy loss. Swanson and her students followed up with a conceptual model of miscarriage (Wojner, Swanson, & Adolfsson, 2011), a secondary analysis ( Huffman, Schwartz, & Swanson, 2015 ), and development of the meaning of miscarriage scale ( Huffman, Swanson, & Lynn, 2014 ). Further and extended evidence of her work is found in the empirical literature related to parents’ experiences with children undergoing congenital heart surgery ( Wei Roscigno, Hanson, & Swanson, 2015 ; Wei et al., 2016 ).
Recently, Swanson supplemented her theory by presenting a connection between caring and healing ( Swanson, 2015 ), maintaining that “when a provider takes the time to know, be with, do, enable, and maintain belief in the other, the recipient feels a sense of wholeness” (p. 530). While some would classify Swanson’s Theory of Caring and Healing as a practice or situational theory (since it was developed as an outcome of studying a limited patient population), others have used it beyond pregnancy loss to guide professional practice and curricula. For example, the theory was implemented in a large health system in the Southeast, and improvements were noted in patient and nurse satisfaction levels, patient pain, and response to call lights (Tonges & Ray, 2011). Swanson continues to work with students and faculty members in her role as Dean at the University of Seattle and with health systems as they implement cultures of caring. Swanson’s persistence in observing, applying, validating, and refining the Caring and Healing Theory provides an exemplary model of the relationship between theory and research.
THE QUALITY–CARING MODEL© (JOANNE R. DUFFY)
Developed to fill a perceived practice and research void in the late 1980s, the Quality–Caring Model was initially informed by Duffy’s involvement in quality improvement and clinical experiences with acute hospitalized patients who, when asked about their dissatisfaction with care, verbalized, “no one cares.” In these encounters with acutely ill hospitalized adults, Duffy observed that the fundamental patient–nurse caring relationship (a deeply held disciplinary value) was frequently marginalized from the often routine task-oriented nature of nursing work. This incongruity between professional values and work behaviors was considered serious because, as Duffy began to investigate, nurses linked it to work dissatisfaction and patients linked it to poorer health outcomes, both important indicators of healthcare quality.
Corroborated by the consequences of noncaring as reported in the literature ( Reiman, 1986 ), Duffy first set out to narrow the gap between disciplinary values and behaviors and current professional practice by studying the linkage between nurse caring relationships and quality, with the ultimate intention of demonstrating how nurse caring contributes to improved patient outcomes. After developing the Caring Assessment Tool (CAT) to measure patients’ perceptions of caring, Duffy used this instrument to conduct the original study that significantly associated nurse caring to patient satisfaction ( 1990 , 1992 ). The CAT was later adapted to assess student nurses’ perceptions of faculty caring (via the CAT-edu) and staff nurses’ perceptions of nurse managers’ caring (via the CAT-adm); findings demonstrated a positive relationship between nurse manager caring behaviors and staff nurse satisfaction ( Duffy, 1993 , 2008 ). Continued development and evaluation of the CAT instruments are ongoing. For example, an exploratory factor analysis of the CAT in 2007 and again in 2010 pointed to a one-factor solution and assisted with item reduction ( Duffy, Brewer, & Weaver, 2010 ; Duffy, Hoskins, & Seifert, 2007 ). A factor analysis of the CAT-adm was recently completed, and new instruments, namely, patient perceptions of team caring, the caring intention scale, and the caring capacity scale, are presently under development or evaluation. Graduate students, individual researchers, nursing faculty members, and health systems throughout the world routinely use these instruments for assessment of caring relationships in varying contexts.
With valid and reliable instruments now available, Duffy continued her program of research but was …