Nursing As Caring: a Model for Transforming Practice

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.

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.

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