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 )