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

REFERENCES

ACKNOWLEDGEMENTS

CHAPTER I — FOUNDATIONS OF NURSING AS CARING

CHAPTER II. — NURSING AS CARING

CHAPTER III — NURSING SITUATION AS THE LOCUS OF NURSING

CHAPTER IV. — IMPLICATIONS FOR PRACTICE AND NURSING SERVICE ADMINISTRATION

CHAPTER V. — IMPLICATIONS FOR NURSING EDUCATION

CHAPTER VI — THEORY DEVELOPMENT AND RESEARCH

EPILOGUE

CONCLUSION

REFERENCES

INDEX

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.

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.

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.

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.

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

REFERENCES