Nursing as Caring: A Model for Transforming Practice
Summary
Play Sample
The image of a dancing circle is also used to describe being for and being with the nursed. In the circle, all persons are committed to knowing self and other as living and growing in caring. Each dancer makes a distinct contribution because of the role assumed. The dancers in the circle do not necessarily connect by holding hands although they may. Each dancer moves within this dance as called forth by the nature of the nursing situation. The nursed calls for services of particular dancers at various points in time. Each person is in this circle because of their unique contribution to the person being cared for ... nurses, administrators, human resources, etc. These roles would not exist if it were not for the nursed. There is always room for another person to join the dance. Rather than the vertical view described earlier, this model fosters knowing other. Eye-to-eye contact assists one to know and appreciate each other as caring persons. Each person is viewed as special and caring. No one person's role is more or less important than the other's. Each role is essential in contributing to the process of living grounded in caring. As each person authentically expresses their commitment in being there for and with the nursed, caring relationships are lived. When the focus in any health care institution fails to be the person cared-for, purpose, roles, and responsibilities become depersonalized and bureaucratic rather than person-centered and caring.
Personal knowing—knowing of self and other—is integral to the connectedness of persons in this dance. The nursing administrator interfaces with persons of many disciplines as well as with the nursed. With each interaction, the nurse administrator is honest and authentic in encouraging others to know and live out who they are. Each encounter with another is an opportunity for knowing other as caring person. From an organizational standpoint the nursing administrator assists in creating a community that appreciates, nurtures, and supports each person as they live and grow in caring moment to moment. The nursing administrator assists nurses to hear and understand the unique calls for nursing and supports and sustains their nurturing response.
REFERENCES
Benner, P, & Wrubel, J. (1989). The primacy of caring: Stress and coping in health in illness. CA: Addison-Wesley. Bohm, D. (1992). On dialogue. Noetic Sciences Review, pp. 16-18. Boykin, A. (1990). Creating a caring environment: Moral obligations in the role of dean. In M. Leininger & J. Watson (Eds.) , The caring imperative in education. New York: National League for Nursing, pp. 247- 254. Cassarrea, K. , Millis, J. , & Plant, M. (1986). Improving service through patient surveys in a multihospital organization. Hospital and Health Services Administration, 31 (2), 41-52. Duffy, J. (1992). The impact of nurse caring on patient outcomes. In Gaut, D. (Ed.) . The presence of caring in nursing. New York: National League for Nursing, pp. 113-136. Gadow, S. (1984). Touch and technology: Two paradigms of patient care. Journal of Reli-gion and Health, 23,63- 69. Kahn, D. , & Steeves, R. (1988). Caring and practice: Construction of the nurse's world. Scholarly Inquiry for Nursing Practice, 2 (3), 201- 215. Knowlden, V. (1986). The meaning of caring in the nursing role. Dissertation Abstracts International, 46 (9), 2574-A. Kronk, P. (1992). Connectedness: A concept for nursing. Unpublished manuscript. Little, D. (1992). Nurse as moral agent. Paper presented at University of South Florida Year of Discovery Seminar, Sept. 1992. Mayeroff, M. (1971). On caring. New York: Harper & Row. Orlando, I (1961). The dynamic nurse-patient relationship. New York: G. P. Putnam's Sons. Paterson, J. , & Zderad, L. (1988). Humanistic nursing. New York: National League for Nursing. Riemen, D. (1986a). Noncaring and caring in the clinical setting: Patients' descriptions. Topics in Clinical Nursing, 8,30-36. Riemen, D. (1986b). The essential structure of a caring interaction: doing phenomenology. In P. Munhall & C. Oiler (Eds.) . Nursing research: A qualitative perspective. Norwalk, CT: Appleton-Century- Crofts. Roach, S. (1987). The human act of caring. Ottawa: Canadian Hospital Association. Samarel, N. (1988). Caring for life and death: Nursing in a hospital-based hospice. Dissertation Abstracts International, 48 (9), 2607-B. Swanson-Kauffman, K. (1986a). Caring in the instance of unexpected early pregnancy loss. Topics in Clinical Nursing, 8,37-46. Swanson-Kauffman, K. (1986b). A combined qualitative methodology for nursing research. Advances in Nursing Science, 8,58-69. Swanson, K. (1990). Providing care in the NICU: Sometimes an act of love. Advances in Nursing Science, 13 (1), 60-73. Tead, 0. (1951). The art of administration. New York: McGraw-Hill. Tournier, P. (1957). The meaning of persons. New York: Harper & Row. Wheeler, L. (1990). Healing-HIV+. Nightingale Songs, P. O. Box 057563, West Palm Beach, FL 33405-7563, 1 (2). Winland-Brown, J. , & Schoenhofer, S. (1992). Unpublished research data. Yelland-Marino, T. (1993). Last rights. Nightingale Songs, P. O. Box 057563, West Palm Beach, FL 33405-7563, 3 (1).
CHAPTER V. — IMPLICATIONS FOR NURSING EDUCATION
In this chapter, we address the implications of our theory for nursing education, including designing, implementing, and administering a program of study. The assumptions that ground Nursing as Caring also ground the practice of nursing education and nursing education administration. The structure and practices of the education program are expressions of the discipline and, therefore, should be explicit reflections of the values and assumptions inherent in the statement of focus of the discipline. From the perspective of Nursing as Caring, all structures and activities should reflect the fundamental assumption that persons are caring by virtue of their humanness. Other assumptions and values reflected in the education program include: knowing the person as whole and complete in the moment and living caring uniquely; understand that personhood is a process of living grounded in caring and is enhanced through participation in nurturing relationships with caring others; and, finally, affirming nursing as a discipline and profession.
The curriculum, the foundation of the education program, asserts the focus and domain of nursing as nurturing persons living caring and growing in caring. All activities of the program of study are directed toward developing, organizing, and communicating nursing knowledge, that is, knowledge of nurturing persons living caring and growing in caring.
The model for organizational design of nursing education is analogous to the dancing circle described earlier. Members of the circle include administrators, faculty, colleagues, students, staff, community, and the nursed. What this circle represents is the commitment of each dancer to understanding and supporting the study of the discipline of nursing. The role of administrator in the circle is more clearly understood when the origin of the word is reflected upon. The term administrator is derived from the Latin ad ministrare, to serve (Guralnik, 1976). This definition connotes the idea of rendering service. Administrators within the circle are by nature of role obligated to ministering, to securing and to providing resources needed by faculty, students, and staff to meet program objectives. Faculty, students, and administrators dance together in the study of nursing. Faculty support an environment that values the uniqueness of each person and sustains each person's unique way of living and growing in caring. This process requires trust, hope, courage, and patience. Because the purpose of nursing education is to study the discipline and practice of nursing, the nursed must be in the circle. The community created is that of persons living caring in the moment, each person valued as special and unique.
We have said in Chapter 1 that the domain of a discipline is that which its members assert. The statement of focus that directs the study of nursing from this theoretical perspective is that of nurturing persons as they live caring and grow in caring. The study of nursing is approached through the use of nursing situations. The knowledge of nursing resides in the nursing situation and is brought to life through study. The nursing situation is a shared lived experience in which the caring between the nurse and the one nursed enhances personhood or the process of living grounded in caring. These situations, like the many cited in earlier chapters, become available for study through the use of story (recounting the situation in ways that convey the essence of the lived experience). These stories create anew the lived experience of caring between the nurse and the nursed, and bring to life the basic values described in Chapter 1.
Story then becomes the method for studying and knowing nursing. Carper's (1978) four patterns of knowing serve as an organizing framework for asking epistemological questions of caring in nursing. Those patterns include personal, ethical, empirical, and aesthetic knowing. Each of these patterns comes into play as one strives to understand the whole of the situation. Personal knowing centers on knowing and encountering self and other, empirical knowing addresses the science of caring in nursing, ethical knowing focuses on what "ought to be" in nursing situations, and aesthetic knowing is the integration and synthesis of all knowing as lived in a particular situation. The poem, "Intensive Care," a representation of a nursing situation, is given here to illustrate the organization of sample content.
INTENSIVE CARE
Did you see nurse that you can know me—
The part that is me, my mind and soul is in my eyes
These tubes that are everywhere-that is not me.
The one in my throat is the worse of all—
Now my whole being, the essence of me I
must reflect
through my hands but they are tied down,
movements
of my head but did you realize that
uncomfortable for me
or through my eyes and you do not notice them—
except once today during my bath.
You speak to me and look at the tubes—
Don't you know my thoughts are all over my face
Don't you realize your thoughts are on your face—
In your touch and your tone of voice.
I wrote a request on paper and you said "I'll take care
Of it for you" your tone said "Why can't this
woman
Do anything for herself?"
You positioned your hand to count my pulse but I
Can't say you touched me-you wouldn't hold my
hand that I may touch you.
You walked in for the first time today with a grin
on your face but your mouth is now tight
you grimaced a lot as you bathed me.
Don't you see nurse that you can know me—I'm not
A chart or tubes of medication, monitors or all
the other things you look at so intensely—I'm
more than that
I'm scared—just look in my eyes.
—S. Carr, 1991
Carper's (1978) patterns of knowing offer a framework for organizing the content for studying this nursing situation.
PERSONAL KNOWING
Who are the nurse and nursed as caring persons in the moment? How are the nurse and nursed expressing caring in this moment? What is the meaning of this situation to the nurse and nursed in terms of present realities and future possibilities? What is the meaning of vulnerability and mortality? What is the value of intuition in practice? Empirical Knowing What nursing and related research exists on modes of communication, the meaning of presence in practice, touch, objectification, recovery of cardiac patients, technological caring, understanding the experience of fear and loneliness? What factual knowledge is needed to be competent in this particular situation—e.g. knowledge of monitors, chest tubes, medications, cardiac care, diagnostic data?
ETHICAL KNOWING
If nursing is practiced from the perspective of Nursing as Caring, what obligations are inherent in this situation? How is the nurse demonstrating the value that all persons are caring? Respect for person-as-person? Interconnectedness? What dilemmas are present in this story?
AESTHETIC KNOWING
How is the nursed supported to live dreams of living and growing in caring? How could the nurse transcend the moment to create possibilities within this specific nursing situation? What metaphors might express the meaning of this nursing situation?
Students studying this nursing situation are challenged to know the person as caring, as living caring uniquely in the moment, as having hopes and dreams for growing in caring, and as being whole or complete in the moment. The student is also challenged to know the nurse as caring person in the moment and to project ways of supporting the nurse as caring person.
Through the study of this situation, students and faculty identify a range of calls for nursing as well as nurturing responses. In this process, there is dialogue focused on knowing the nurse and nursed in the story as caring person. We would contribute the following as our knowing of the nursed as caring person. Through her honest expression of "I'm scared—just look in my eyes," we know her as living hope, honesty, and transcending fear through courage.
Calls for nursing might include a call to be known as caring person and a call to have interconnectedness recognized and affirmed. The nurse's response to these calls is individual and evolves from who one is as person and nurse. Therefore, the range of responses is multiple and varied—each reflecting the nurse's informed living of caring in the moment. Each nurturing response is focused on nurturing the person as he or she lives caring and expresses hopes and dreams for growing in caring.
If the nurse is responding to the call of the person for recognition and affirmation of interconnectedness, perhaps the nurse would express hearing this call by being present with the intention of knowing other as caring person. This may be communicated through active patience—giving the other time and space to be known; through touch which communicates respect and interconnectedness; through the nurse sharing who he or she is as caring person in this relationship—perhaps through tears as the resonance of commonality of this experience is known; through music or poetry if a shared love of these has been discovered.
Through dialogue, students and faculty openly engage in the study of nursing. The dialogue encourages and supports students and faculty to freely express who they are as person and nurse living caring through the re-presented story. It provides an opportunity to affirm values of self and discipline and to study how these values may be lived in practice. It is in this dialogue of nursing that faculty communicate their love for nursing. Time is needed for both faculty and students to reflect on the meaning of being a member of this discipline and more specifically, on the meaning of being a member of a discipline focused on nurturing persons as they live and grow in caring. Dialogue facilitates the integration of this understanding and is a key concept in present and future transformations of nursing education. Common engagement in dialogue as nursing stories are shared and studied is the way of being.
The story lived anew provides students the opportunity to participate in a lived experience of nursing and to create new possibilities. Since nursing can only occur through intentionality and authentic presence with the nursed, students and faculty share how they prepare to enter the world of the nursed, and how they come to understand that world. This process requires that students be encouraged to live fully their personhood. To facilitate such living, faculty support an environment in which students are free to choose and to express self in various ways. For example, perhaps the holistic understanding of a nursing situation would be expressed as aesthetic knowing through dance, poetry, music, painting, or the like. We view this process of education as critical to moral education. When students enter nursing situations to know other as living and growing in caring, they are living out the moral obligation that arises from the commitment to know person as caring. Here, then, is an expression of a dynamic view of morality in which caring is always lived in the moment.
In the study of the situation, Intensive Care, brought to the dialogue are personal experiences of being alone, being afraid, and being with someone and not being heard or seen as caring person. This personal knowing fosters human awareness of our connectedness and interdependence. In this context, the nurse does not study the empirics of cardiac pathology to understand a perceived deficit but rather to become competent in drawing forth the knowledge that is specific to knowing this person as whole in the moment. The nurse comes to know the person as living caring and growing in caring, situated within a particular set of circumstances, some of which the nurse knows explicitly. Each student entering the nursing situation will ask, "How can I nurture this person in living and growing in caring in this situation?" Because each nurse may hear calls for caring in many different ways, nursing responses are many and varied. For nursing faculty, openness to multiple possibilities presents a particular challenge and an opportunity to suspend entrenched patterns of teaching nursing.
Faculty and students study nursing together. Faculty join students in a constant search to discover the content and meaning of the discipline. Undoubtedly, this understanding of extant possibilities presents a different view of the role of teacher. Yet, it is a view that engenders the sort of humility essential to nursing for there is always more to know. Although past methods of teaching of nursing may have been comfortably structured through textbooks organized around medical science, faculty are now empowered to question what should be the focus of study in the discipline of nursing. Faculty are encouraged to take risks and let go of the familiar. The perspective that Nursing as Caring conveys—the fullness and richness of nursing—will allow faculty to willingly assume the risks inherent in a new way of guiding the study of nursing.
In teaching Nursing as Caring, faculty assist students to come to know, appreciate, and celebrate self and other as caring person. Mayeroff's On Caring (1971) provides a context for the generic knowing of self as caring. Through dyads or small groups, students share life situations in which they experienced knowing self and other as caring person. Mayeroff's caring ingredients (knowing, alternating rhythm, trust, honesty, hope, courage, humility, patience) also serve as a source for reflection as one asks "who am I as caring person?" . As students engage in this exercise, their emerging reflections begin to ground them as they grow in their understanding of person as they live and grow in caring. Students will also draw on the knowledge gleaned in the study of arts and humanities as they attempt to gain a deeper understanding of person. The process of knowing self and other as caring is lifelong. In an educational program grounded in Nursing as Caring, however, the focus on personal knowing (in the study for every nursing situation) provides a deliberate opportunity for greater knowing of self and other as caring person.
Students, as well as faculty, are in a continual search to discover greater meaning of caring as uniquely expressed in nursing; journaling is an approach that facilitates this search. For example, in a special form of journaling, students actively dialogue with authors whose works they are reading and with the ideas expressed in their works. This process enhances the students' understanding of caring in nursing. Over time, students integrate and synthesize many ideas and create new understandings. Examination is another process to facilitate learning. From this theoretical perspective, essay examinations that present nursing situations provide opportunities for students to express their knowledge of nurturing persons living and growing in caring. Aesthetic projects also allow the student the opportunity to communicate understanding of a nursing situation. We would like to share with you a project from a course in which the students were asked to express the beauty of a nursing situation. In this nursing situation, the nurse, Michelle, shared her gifts of therapeutic touch and voice as expressions of caring for David in the moment, drawing on an earlier dialogue in which David told her of his love of meditation and the Ave Maria, she wrote:
AVE MARIA AND THERAPEUTIC TOUCH FOR DAVID "David, let me know your pain; From fractured leg and heart, Share with me your private hell. Next to one who's far, Far away his own world: Moaning, crying, weak. What's it like to lie beside One who cannot speak? "Tell me David, what you do To cancel out the sound; Eliminate the smell of dung In which your roommate's found? Who can you complain about? Are you worse off than he? Tied to IV, traction lines You cannot be free. "David, I can see your pain. Tell me where you are. Tied in bed. Powerless. From loved ones you're apart. I can't move you from this place To take your pain away. But let me lay my hands on you And sing to you today." Ave Marie, gratia plena Maria, gratia plena. Ave dominus, dominus tecum. Benedicta to in mulieribus. Et benedictus Et benedictus, fructus ventris; Ventris tui, Jesu. Ave Maria I sang the song he loved and used To meditate and flee, Escape tormenting stimuli. He needed to be freed, To understand why he must bear This trial, this hell, this pain, I sang the tune; I touched with care To give him peace again. —Stobie, 1991
Expressions of nursing such as this, which was partly sung, beautifully portray the living of caring between the nurse and the nursed and exemplify how caring enhances personhood. Faculty play a vital role in fostering in students the courage to take such risks. Faculty encourage self-affirmation in students, open, nonjudgmental dialogue, living the caring ideal in the classroom and development of the students' moral groundedness in caring (Boykin & Schoenhofer, 1990). Faculty also take the risk of sharing self through their stories of nursing. The sharing of nursing situations is, in essence, a sharing of our innermost core of common identity and forms a type of collegiality among those who are studying the discipline together.
How can faculty be supported to teach nursing in new ways? The administrator of the program fosters a culture in which the study of the discipline from the caring perspective, as presented here, can be achieved freely and fully. All actions of the dean are directed toward creating, maintaining, and supporting this goal. The theoretical assumptions ground the activities of the dean in both internal and external areas of responsibility.
Internally, the administrator, faculty, staff, and students model commitment by creating an environment that fosters the knowing, living, and growing of persons in caring. The dean "ministers" by assuring that faculty, students, and staff are presented ongoing opportunities to know themselves ontologically as caring persons and professionals and to understand how caring orders their lives. Who we are as person influences who we are as student, colleague, nurse, scholar, and administrator. Therefore, attention must be directed to knowing self. Time must be devoted to knowing and experiencing our humanness.
The constant struggle to know self and other as caring person nourishes our knowing of the nursed. Through constant discovery of self, the other is also continually discovered. This culture sensitizes each person to ways of being with other that necessitate that each action reflect respect for person as person. Therefore, when issues are to be addressed, they are addressed openly and fully. Persons are encouraged to bring forth who they are so there is congruence between actions and feelings. Understanding each other's views is essential to the unfolding of this culture. Dialogue assists one to know the other's needs and desires, and to image oneself in the other's place. As such, the dean, faculty, staff, and students become skilled in the use of the caring ingredients, internalized as personally valid ways of expressing caring: knowing, alternating rhythms, trust, hope, courage, honesty, humility, and patience (Mayeroff, 1971).
Of utmost importance in fostering this culture are decisions regarding selection of faculty. Although many prospective faculty have a fairly traditional lens for the study of nursing (that is, the lens of medical science or frameworks borrowed from other disciplines), this actually becomes an insignificant factor in the process of selection. At the heart of choosing new faculty is knowing their passion for and love of nursing. A focus of the interview process is discerning the person's devotion to the discipline. It is our belief that this attitude, this love of nursing, is the music for the dancers in the circle. One way to know if prospective faculty love nursing is to ask them to share a significant story from practice. Having faculty share a story illuminates their conceptualization of the discipline. Many faculty who have not had the opportunity to teach nursing through an articulated nursing lens, can yet communicate nursing clearly through story.
Faculty are supported in their struggles to conceptualize nursing in a new way. Forums in which faculty come together and aesthetically re-present and share their nursing story is one strategy that effectively engages self and other in the knowing of nursing. It is also a wonderful way to orient faculty as to how to use nursing situations to teach nursing. Faculty support each other as colleagues in learning to teach nursing in a new way, in becoming expert in the practice of nursing education, and in living out the basic assumptions of this theory. This need for support holds true not only for faculty-faculty relationships but for all relationships. The comfort of faculty teaching nursing from the perspective of Nursing as Caring is enhanced as the value of knowing other as caring, as living our histories and as having special nursing stories to share is appreciated.
The administrator, faculty, and staff assist in fostering an environment that furthers the development of the students' capacity to care. Competency in caring is a goal of the educational process. Students are continually guided to know self and other as caring person as faculty and administrators model actions that reflect respect for person as person. Each student is known as caring person, as special and unique. Policies allow for consideration of individual situations and diverse possibilities. In this culture, the dean and faculty attempt to know the student as caring person and student of the discipline. The intention of the dean to know students in this way can be evident through invitations for regularly scheduled dialogue in which students share openly their conceptions about nursing. The administrator is truly with students to know them as caring persons and to hear from them their understanding of nursing as caring.
Externally, the dean "ministers" to faculty, students, and staff through securing resources necessary to accomplish program goals. The dean articulates to persons in the academic and broader community their role in the dance of nursing. The role of these persons is to provide resources such as scholarships, faculty development possibilities, learning resources, and research monies. Although this may be a primary responsibility of the dean by nature of the role, all persons in the circle share in this process by virtue of their commitment to nursing.
The administrator brings to the circle a skillful use of the caring ingredients. Alternating rhythms are used to understand and appreciate each person's unique contributions that support the achievement of program goals. For example, the budgetary process is essential to creating an environment that reflects the valuing of nursing. Commitment of the dean to securing resources necessary to accomplish the program goals drives the budget rather than the budget driving the commitment. The administrator's devotion to the discipline and to the basic assumptions of the theory direct all activities. The administrator makes decisions that reflect the basic beliefs of this theory. All decisions would ultimately be made from this standpoint: "What action should I take as administrator which would support the study of nursing as nurturing persons living in caring and growing in caring?"
What we have tried to suggest here is that every aspect of nursing education is grounded in the values and assumptions inherent in this theoretical focus. Thus, not only is the curriculum a direct expression of Nursing as Caring, but all aspects of program are similarly grounded.
REFERENCES
Boykin, A. , & Schoenhofer, S. (1990). Caring in nursing: Analysis of extant theory. Nursing Science Quarterly, 4, 149-155. Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1, 13-24. Carr, S. (1991). Intensive Care. Nightingale Songs, PO. Box 057563, West Palm Beach, FL 33405-7563, 2 (1). Guralnik, D. (1976). Webster's new world dictionary of the American language. Cleveland: William Collings + World Publishing Co. Mayeroff, M. (1971). On caring. New York: Harper & Row. Nodding, N. (1988). An ethic of caring and its implications for institutional arrangement. American Journal of Education, 97, 215-230. Roble, M. (1991). Ave Maria and Therapeutic Touch for David. Nightingale Songs, P. O. Box 057563, West Palm Beach, FL 33405-7563, 1 (3).
CHAPTER VI — THEORY DEVELOPMENT AND RESEARCH
In this chapter, we will address our conception of nursing as human science and suggest directions and strategies for further development of the theory of Nursing as Caring. We initially introduced our perspective of nursing as discipline and profession in Chapter 1 and as a grounding context for the theory. As a discipline, nursing is a way of knowing, being, valuing, a way of living humanely, connected in oneness with others, living caring and growing in caring. The unity nursing offers is known in human experience through personal, empirical, ethical, and aesthetic realms.
Science has to do with knowing and that which is known. Philosophers of science are concerned with valid ways of knowing and ways of validating that which is known. Human science is described by scholars in various ways, each emphasizing particular values but all connecting to a common understanding that human science is concerned with knowing the world of human experience. A committed inquiry into human experience seems to call forth certain values related to the meaning of being human. Herein lies the fundamental difference between formal science and human science, as we perceive it. Formal science, that which is practiced in the natural sciences and other sciences that emulate them, is modeled on the structure of mathematics. Mathematics is a highly lawful science that has contributed enormous social benefits over time. However, formal science grounded in mathematics and languaged as calculus is an inappropriate approach to the study of person-as-person. A perspective that addresses the phenomenon of person-as-person is grounded in central values such as caring, freedom, and creativity. Methods to study person must be similarly grounded.
We have come to understand that valid ways of knowing nursing and legitimate warrants for nursing knowledge are discovered from within the study of nursing itself; that is, within the study of the nursing situation. The manner in which certain disciplines are conceptualized, especially those dealing in normative contexts, calls for a dialectical form of sciencing, comparing, and contrasting. However, coming to know nursing is a dialogical process—direct engagement with the "word of nursing." Nursing science must be contextual; the decontextualized methodology of formal science, while essential for certain disciplines, cannot reveal direct knowledge of nursing. Because of the nature of nursing, nursing science must permit intentionality, intimacy, mutuality, and particularity.
Human science has understanding as its goal, with the definite expectation that understanding is in the moment only (Watson, 1988; Van Manen, 1990). In addition, the nature of nursing praxis does not require knowledge for the purpose of control, but for enlightenment, moment-to-moment and reflectively. The nurse seeks knowledge neither to control one's own behavior or that of the nursed. If it were otherwise, the nurse would become his or her own prisoner, and would relate to the other as dominator rather than caring nurse. The concept of the hermeneutic circle informs our understanding of the nature of nursing as a human science. This circle of understanding, really a sphere more than a uni-dimensional circle, is a heuristic device which directs our attention. As attention pauses at any aspect of the nursing situation, we must attend to other aspects and to the whole of the nursing situation to create useful understanding. One hermeneutist has pointed out that the circle brings us further along, not the issue at hand (Droysen, 1988). This distinction points to the human science position that understanding is not constituted through analysis of facts but through dialogue with text and context. That is, what moves within the circle is the seeker, rather than that which is sought, so that many aspects are illuminated in context, and understanding grows. The hermeneutic circle requires that what we note in our inquiry remains contextualized, developing "new and ever new circles" (Boeckh, 1988). This is in contrast to normal science that requires an external referent for objects of study in order to avoid circular thinking. Heidegger (1988), for example, contrasts the vicious circle of normal science (tautology) with the circle of hermeneutic: " . . . in the circle is hidden a positive possibility of the most primordial kind of knowing" (p. 225). We would propose that valid knowing in nursing is that which is known from within the circle.
While the work of several scholars has influenced our understanding (e.g. , Gadamer, 1989; Van Manen, 1990; Ray, 1994; Reeder, 1988), Macdonald's (1975) interpretation from the field of humanistic education is especially meaningful. He explains hermeneutic knowing methodologically as "circular rather than linear in that the interpretation of meaning in hermeneutic understanding depends on a reciprocal relation" (p. 286) rather than on a fixed normative reference point. The hermeneutic circle models the idea of reciprocal relation, but Macdonald goes further to call for a self-reflective science that will "transcend problems of monological and hermeneutic meaning" (p. 287). The nature of nursing as expressed in the Nursing as Caring theory is a reciprocal relation, one characterized by its grounding in person as caring, and as persons connected in oneness in caring. Sciencing in nursing from this perspective must go beyond linearity to encompass the dialogic circling involved in the nursing situation. This places the discipline of nursing among the human sciences, and calls for methods of inquiry that assure the circle or dialogue, and further, fully accommodate that which can be known of nursing.
Nursing is properly catalogued as one of the human sciences for many reasons. The most basic reason is that the discipline and the disciplined practice of nursing directly involve persons in the fullness of their humanness. From our perspective, this means person as caring. Person as caring implies person in community, connected in oneness with others and with the universe, person freely choosing the living of values which are expressions of caring. This nursing ontology requires an epistemology consonant with human science values and methods. To know of, through and with nursing necessitates methods and techniques that honor freedom, creativity, and interconnectedness.
In Chapter 4, we asserted that nursing knowledge is created and discovered within and from within the nursing situation. (Nursing situation, you may recall, is understood as a shared lived experience in which the caring between the nurse and the one nursed enhances personhood.) Therefore, because the locus of nursing inquiry is the nursing situation, the systematic study of nursing calls for a new methodology that recognizes that fact.
Certainly, we acknowledge that something useful for nursing can be learned through existing methodologies, from both natural and human science traditions. For example, an experimental design can produce information about the effectiveness of a given clinical technique within a specified range of use (e.g. , placement of an oral thermometer). Such information can be important and useful to the work of the nurse and useful to the client of nursing. It tells us nothing, however, of nursing. In fact, the central tenet underlying measurement in normal science directly contradicts the central tenet of human science: created versus creating. Thus, the fullness of the nursing situation is not amenable to study by measurement techniques. Yet, aspects of the nursing situation can be abstracted and studied as variables in relation to other variables. This does not, however, yield knowledge of the nursing situation in its fullest. At best, measurement approaches can call attention to an aspect so that it can be considered within the unfolding.
Phenomenology, on the other hand, offers an example of an orientation and methodology that more closely approximates what is needed in a nursing method of inquiry. Phenomenology is an orientation toward inquiry that may be actualized through any one of a number of generic approaches, but is generally understood as the study of lived experience (e.g. , Van Manen, 1990; Oiler, 1986). When the phenomenon conceptualized for study is representative of the nursing situation, nursing may be known. That is, new nursing knowledge may eventuate. New understanding of the meaning of the shared lived experience of caring between nurse and nursed enhancing personhood can be created.
Yet, for the purposes of nursing, phenomenology also has its limits. For example, when phenomena which have been abstracted from a nursing situation are selected for study (that is, when phenomena are taken out of context), results of the inquiry cannot generate knowledge of nursing proper. For example, the understanding that comes in developing a description of the essential structure of what it is like for a nurse to be called to nurse informs us about nurses, but not about nursing directly. Similarly, an exquisite phenomenological description of what it is like for a person to live grieving is helpful in understanding the person. However, it should not be mistaken for knowledge of nursing, but knowledge which illuminates the study of nursing when taken back to the full context of the nursing situation. Further, the various phenomenologies in the literature come from frames of reference that are not nursing (e.g. , existential psychology or educational psychology), and thus impose a "silent" borrowed framework when used to study nursing.
Is this drawing too fine a line? And is it really important to press the issue of nursing knowledge versus knowledge of and for nurses? The answers to these questions are probably found in one's concept of nursing as a field of knowledge (discipline) and a human service (profession). It seems that nursing and nurses have suffered significantly over the years with this dilemma. Is it possible to have a sense of self as nurse without a concomitant sense of nursing as a discipline which is more than tacit and to which one is committed? Students of nursing and practitioners alike have abundant opportunities to acquire a sense of self as nurse. Yet why is it that many programs of nursing education (at all levels) do not convey a sense of nursing as a discipline? The answer may lie in those conducting the programs, who have experienced training for practice and education in disciplines other than nursing and without explicit education in the discipline of nursing.
From the perspective of Nursing as Caring, with its grounding in person as caring and nursing as discipline, the distinctions implied in this question of "does it really matter" are of central importance. Nurses in practice, education, and administration continue to address nursing primarily in terms of "what nurses do," (e.g. , nursing "interventions") and most nursing research seems to derive from that perspective as well. Without a clearly articulated understanding of the focus of the discipline, it has been extremely difficult to organize and structure nursing knowledge in ways that facilitate the development of the discipline. In this book, we have offered a theory, Nursing as Caring, as one expression of that focus, languaged in terms that communicate the essence of nursing.
Nursing knowledge is knowledge of nurturing persons living caring and growing in caring within shared lived experiences in which the caring between nurse and nursed enhances personhood. Furthering nursing knowledge requires methods that can illuminate the central phenomenon of the discipline. The development of such a methodology is, as we see it, the next major effort to be undertaken in the development of the theory. In this regard, we envision a fully adequate methodology that would include a phenomenological aspect which goes beyond description to a hermeneutical process, within an action research orientation. That is, what seems to be needed is a methodology that would permit the study of nursing meaning as it is being co-created in the lived experience of the nursing situation. Supplemental methods could continue to include traditional phenomenological and hermeneutic work with texts describing particular nursing situations. Nurses who are interested in developing knowledge of techniques or modes of expressing caring would continue to use traditional methods of formal and human science for these kinds of nursing-related questions.
The development of methods of nursing inquiry appropriate to the study of the theory, Nursing as Caring, is in a formative stage. We understand to a considerable extent the limitations of existing modes of inquiry, and have a growing sense of what will be required of a new methodology. Nursing scholars are working to develop methods to illuminate the fullness of nursing. Examples of that work which has encouraged our efforts include that by Parker (1993), Swanson-Kauffman (1986), Parse (1990), and Ray (Wallace, 1992). The work of these scholars demonstrates that the development of nursing ways of inquiry is important and that a search has begun. As we have come to understand the concept of human science, our understanding of nursing has been enriched. Like most of our contemporaries in nursing, we were trained in the often-unarticulated assumptions of natural science. And we have traveled the road familiar to many nursing scholars, the road of expertise in objectification and quantification. Along that road, we began to notice the trivialization of cherished nursing ideas like presence, touch, relationship, knowing, and caring. Resisting the temptation to abandon the journey, we each persevered in a commitment to nursing as something which mattered, something involving intimate, personal, caring relationships. Discovering, inventing, and creating a new methodology is an important dream and we are committed to continuing this aspect of theory development.
Nursing as Caring is a transformational model for all arenas. Nursing practice, nursing service organization, nursing education, and nursing inquiry require a full understanding of nursing as nurturing persons living caring and growing in caring, and these underlying assumptions:
* Persons are caring by virtue of their humanness. * Persons are caring, moment to moment. * Persons are whole or complete in the moment. * Personhood is a process of living grounded in caring. * Personhood is enhanced through participating in nurturing relationships with caring others. * Nursing is both a discipline and profession.
With these transformations, the fullness of nursing will be realized and we will grow in our understanding of self and other as caring persons connected in oneness.
REFERENCES
Boeckh, P. (1988). Theory of criticism. In K. Mueller-Vollmer (Ed.) , The hermeneutics reader. New York: Continuum. Droysen, J. (1988). The investigation of origins. In K. Mueller-Vollmer (Ed.) . The hermeneutics reader. New York: Continuum, pp. 124-126. Gadamer, H. (1989). Truth and method. New York: Crossroad Publishers. Heidegger, M. (1988). Understanding and interpretation. In K. Mueller- Vollmer (Ed.) , The hermeneutics reader. New York: Continuum, pp. 221- 228. Macdonald, J. (1975). Curriculum and human interests. In W. Pinar, Curriculum theorizing: The reconceptualists. Berkeley: McCutchan Publishers. Oiler, C. (1986). Phenomenology: The method. In P. Munhall & C. Oiler (Eds.) , Nursing research: A qualitative perspective. Norwalk, CT: Appleton-Century-Crofts. Parker, M. (1993). Living nursing values in nursing practice. Paper presented at 7th Annual Conference of the Southern Research Association, Birmingham, AL, February 18,1993. Parse, R. (1990). Parse's research methodology with an illustration of the lived experience of hope. Nursing Science Quarterly, 3,9-17. Ray, M. A. (1994). The richness of phenomenology: Philosophic, Theoretic and Methodologic Concerns. In J. Morse (Ed.) , Critical issues in qualitative research. A contemporary dialogue. Newbury Park, CA: Sage, Ch. 7. Reeder, F. (1988). Hermeneutics. In B. Sarter (Ed.) , Paths to Knowledge. New York: National League for Nursing. Swanson-Kauffman, K. (1986). A combined qualitative methodology for nursing research. Advances in Nursing Science, 8 (3), 58-69. Van Manen, M. (1990). Researching lived experience. London, Ontario: State University of New York Press. Wallace, C. (1992). A conspiracy of caring: The meaning of the client's experience of nursing as the promotion of well-being. Unpublished master's thesis, College of Nursing, Florida Atlantic University. Watson, J. (1988). Nursing: Human science and human care. A theory of nursing. New York: National League for Nursing.
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.
CONCLUSION
This epilogue has been written to bring the reader up to date on the development of the theory of Nursing as Caring. Developmental efforts projected in Chapter 6 are still needed, and efforts in progress hold promise for further development. As the cadre of nurses interested in working within the theory grows, development will accelerate, in both projected and novel directions.
Anne Boykin, PhD, RN Professor and Dean College of Nursing Florida Atlantic University
Boca Raton, Florida
October, 2000
Savina O. Schoenhofer, PhD, RN Professor of Graduate Nursing Alcorn State University
Natchez, Mississippi
REFERENCES
Boykin, A. , & Schoenhofer, S. 0. (1993). Nursing as caring: A model for transforming practice. New York: National League for Nursing Press. Boykin, A. , & Schoenhofer, S. 0. (2000). Nursing as caring: An overview of a general theory of nursing. In Parker. M. E. , Ed. , Nursing theories and nursing practice. Philadelphia: F. A. Davis Co. Boykin, A. , & Schoenhofer, S. 0. (1997). Reframing nursing outcomes. Advanced Practice Nursing Quarterly, 1(3), 60-65. Dunphy, L. H. (1998). The circle of caring: A transformative model of advanced practice nursing. 20th Research Conference of the International Association for Human Caring, Philadelphia, Pa. George, J. B. (1995). Nursing theories: The base for nursing practice. (4th ed.) . Norwalk: CT: Appleton & Lange. Kearney, C. & Yeager, V. (1993). Practical Applications of Nursing as Caring theory. In Parker, M. E. , Ed. Patterns of nursing theories in practice. New York: National League for Nursing Press, Ch. 8. Linden, D. (2000). Application of Nursing as Caring in practice. In Parker, M. E. , Ed. , Nursing theories and nursing practice. Philadelphia: F. A. Davis Co. , 1993. Locsin, R. C. (1995). Machine technologies and caring in nursing. Image, 27, 201-203. Locsin, R. C. (1998). Technological competence as caring in critical care nursing. Holistic Nursing Practice, 12(4), 50-56. McCance, T. V. , McKenna, H. P. , & Boore, J. R. P (1999). Caring: Theoretical perspectives of relevance to nursing. Journal of Advanced Nursing, 30, 1388-1395. Parker, M. E. (Ed.) . (2000). Nursing theories and nursing practice. Philadelphia: F. A. Davis Co. Parker, M. E. (Ed.) . (1993). Patterns of nursing theories in practice. New York: National League for Nursing. Parse, R. R. (1987). Nursing science: Major paradigms, theories and critiques. Philadelphia: Saunders. Schoenhofer, S. 0. , Bingham, V. , & Hutchins, G. C. (1998). Giving of oneself on an-other's behalf: The phenomenology of everyday caring. International Journal for Human Caring, 2(2), 23-29. Schoenhofer, S. 0. , & Boykin, A. (1993). Nursing as Caring: Issues for practice. In Parker, M. E. , (Ed). Patterns of Nursing Theories in Practice. New York: National League for Publications, pp. 83-92. Schoenhofer, S. 0. , & Boykin, A. (1998a). The value of caring experienced in nursing. International Journal for Human Caring, 2(4), 9- 15. Schoenhofer, S. 0. , & Boykin, A. (1998b). Discovering the value of nursing in high tech environments: Outcomes revisited. Holistic Nursing Practice, 12(4), 31-39. Smith, M. C. (1999). Caring and the Science of Unitary Human Beings. Advances in Nursing Science, 21(4), 14-28.
INDEX
NURSING AS CARING
A MODEL FOR TRANSFORMING PRACTICE
Anne Boykin,
Savina O. Schoenhofer
Caring is one of the first words that comes to mind when talking about the practice of nursing. Caring is an essential value in the personal and professional lives of nurses. However, the formal recognition of caring in nursing as an area of study is relatively new. Nursing As Caring sets forth a different order of nursing theory.
This new nursing theory is personal, not abstract. The focus of the Nursing As Caring theory is not toward an end product such as health or wellness; it is about a unique way of nurses 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. This is perhaps the most basic, bedrock, and therefore radical, of nursing theories and is essential to all that is truly nursing.