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.