CARING IN NURSING1
Caring in Nursing
Nick Kurek
Ferris State University
CARING IN NURSING1
Abstract
What is caring? What does it mean? What is the importance and purpose of caring? How does it apply to nursing? How do I apply it in my practice? What difference does it make? These are questions that are essential for every nurse to contemplate. Caring is inherent to nursing. This paper explores what is and what is perceived to be caring in nursing. The integration of caring and nursing theory in practice is inevitable and essential. Today’s healthcare environment calls for caring in quality and safety improvement. The reader is left with some proverbial “food for thought” to ruminate upon.
CARING IN NURSING1
Caring in Nursing
What is caring? The Free Dictionary (2013) states “caring is a feeling and exhibiting concern and empathy for others; showing or having compassion”. What is nursing? The Free Dictionary (2013) states “nursing is the practice or profession of caring for the sick and injured; the work of caring for the sick or injured or infirm;the tasks or care of a nurse”. Caring is inherent to nursing. In fact, Lachman (2012) states “caring and nursing are so intertwined that nursing always appeared on the same page in a Google search for the definition of caring” (p. 112). Some consider it to be the heart of nursing.
Theory Base
Caring is an integral part of nursing. Several nursing theorist have caring within the very names of their theories: Jean Watson’s Theory of Human Caring; Marilyn Ray’s Theory of Bureaucratic Caring; Kari Martinsen’s Philosophy of Caring; Katie Erikson’s Theory of Caritative Caring; Dorothy Orem’s Self-Care Theory; Anne Boykin’s and SavinaSchoenhofer’s Nursing as Caring; Madeleine Leininger’s Culture Care; Kristen Swanson’s Theory of Caring; andAdeline Falk-Rafael’s Critical Caring. In fact, caring is either directly addressed or implied in every major nursing theorist’s work from the recognized founder of modern nursing, Florence Nightingale to today’s AdelineFalk-Rafael.
Why is this? Merrill, Hayes, Clukey, & Curtis (2012) inform us “Florence Nightingale wrote that caring is the foundation of nursing practice” (p. 33). TomeyAlligood (2006) quote nursing theorist Marilyn Ray:
Caring is defined as a complex, transcultural, relational process, grounded in an ethical, spiritual context. As such, caring is the relationship between charity and right action, between love as compassion in response to suffering and need, and justice or fairness in terms of what ought to be done. Caring occurs within a culture or society, including personal culture, hospital organizational culture, or society and global culture (M. Ray, personal communication, March 27, 2002) (p.121).
Jean Watson
Jean Watson developed the Theory of Human Caring. It is also known as the Theory of Transpersonal Caring and The Caring Model. Caring is the basis of her theory (see Appendix A). Simply put, Watson’s theory is a holistic approach which addresses the wholeness and calls for the nurse to provide care for both patients and their families on multiple levels including body, mind, and soul/spirit. Her theory is based on 10 Carative Factors (see Appendix B). The 10Carative Factors are known as Caritas. Caritas is the Latin word for charity/love. The Free Dictionary (2013) informs us that in Christian theology caritas is altruistic love (“an unlimited loving-kindness toward all others”) as well asthe greatest of the 3 theological virtues (faith, hope, and charity/love). Watson (2005) explains:
The changing nature of the Carative Factors indicatestheir evolution to incorporate a more explicit relationship between Caring and Love, moving toward using the language of “Caritas,” closely related to the original term Carative but conveying a deep form of transpersonal caring and love to come into play as part of a caring-healing perspective guiding Caring Science (p.3).
Watson’s theory is evolving and is deeply intellectual. There are nurses who are uncomfortable with her views and concepts. Her perspective on caring, as well as her theory for that matter, is complex and can be a little confusing. TomeyAlligood (2006, p. 94) break it down and explain:
Caring is a moral ideal rather than a task-oriented behavior and includes such characteristics as the actual caring moment, phenomena that occur when an authentic caring relationship exists between the nurse and the patient (p. 94).
Madeleine Leininger
Madeleine Leiningeris considered the founder of transcultural nursing. Leininger developed the Theory of Culture Care Diversity and Universality. Caring is the basis of her theory. Vance (2003) states “Madeleine Leininger subscribed to the central tenet that “care is the essence of nursing and the central, dominant, and unifying focus of nursing” (Leinginger, 1991)” (para. 6). Leininger’s Culture Care is rather complex (see Appendix C). TomeyAlligood (2006) quote Leininger:
The purpose of the theory was to discover human care diversities and universalities in relation to world view, social structure, and other dimensions cited, and then to discover ways to provide culturally congruent care to people of different or similar cultures in order to maintain or regain their well-being, health, or face death in a culturally appropriate way (p.476).
The goal of the theory is to improve and to provide culturally congruent care to people that is beneficial, will fit with, and will be useful to the client, family, or culture group in healthy life ways.
Caring is the basis of both Leininger’s and Watson’s theories. It is not surprising to find that Leininger and Watson were co-editors of a book in 1990 titled The Caring Imperative in Education. Theories and concepts continuously evolve. Nurses work with and expand upon existing theories.
Adeline Falk-Rafael
Adeline Falk-Rafaeldeveloped the Critical Caring Theory. Her theory for public health nursing was the natural evolution of other theories. Falk-Rafael (2005) states:
Critical caring transforms the carative processes of Watson’s theory into 7 carative health-promoting processes that form the “core” of public health nursing practice and reflect the legacy and reality of public health nursing practice (p. 38).
Falk-Rafael’s theory is simple, yet complex. It is illustrated in a tree diagram (see Appendix D). Falk-Rafael (2005) explains:
Theory provides roots to ground practitioners of a discipline. Although the tree above the roots may bend with winds of changing trends, although it may be grafted with branches from other trees and evolve in a new variety, theory that is nourished by practice is a living and growing entity that provides support for practice while dynamically defining the characteristics and parameters of practice (p.39).
Abraham Maslow
Abraham Maslow was a psychologist who developed a theory of human development. His theory is illustrated in a familiar 5 level pyramid diagram known as Maslow’s Hierarchy of Needs (see Appendix E). The premise is thateach of the five levels represents a need that must be obtained before an individual can move up to meet the next. The five levels starting from the basic (bottom up) are physiological, safety, love/belonging, esteem, and self-actualization.
Maslow’s theory is taught to all nursing students. It is a way of assessing patients’ needs.Lachman (2012) states “Care is crucial for human development, and is first and foremost aimed at physical needs” (p.114). Caring is essential to reach self-actualization and beyond. Watson (2005) states:
The notion of a living, sacred cosmos, within Reason’s view, can inform our notions of inquiry so we can develop a new kind of sacred science. Thus, such a science that restores the metaphysical integrates “a critical, self-reflexive consciousness with a deep experience of the sacred, and would thus make a major contribution to what Maslow (1971) referred to as the ‘further reaches’ of human nature (Reason, 1993)” (p.25).
Assessment of the Healthcare Environment
Healthcare is a business. Right, wrong, or indifferent healthcare costs money. Our ever increasing understanding of the human body, diseases, and science coupled with corresponding advances in technologies, enable providers with the right resources to provide a higher quality and quantity of life than in years past. This reality brings many questions of quantity verses quality. The evolving field of medical ethicsand the increasing cost of care will inevitably dictate the care that is ultimately provided.
Money matters. Health care facilities need money to provide care. People are much more informed and involved with their care than in years past. Patients and families are aware of the treatment options and choices that are available. The government and insurance companies, who provide reimbursement and as such essentially and arguably dictate healthcare, are also aware of this. As a direct result of this evolution, both quality of care and patient satisfaction have become markers for reimbursement. Jeffs et al. (2013)state:
A renewed focus has been placed on the importance of patient care and family members’ experiences as a key part of quality patient care. Fundamental to nursing practice is establishing therapeutic partnerships with patients and family members to ensure quality care and optimal patient experiences (p.83).
Nursing is becoming increasingly more complex. Nurses must be cognitive of patient satisfaction while providing care for the whole of a person as well as their families/loved ones. The nursing paradigm is shifting.
It must be understood that hospitals are very intimidating and scary places for those that are not in the medical field. The continuous advancement of science, medicine, and technology is readily evident in all the monitors and equipment. Frequently the nurses are very focused on the patient’s physical condition. Moreover with all the technological advances come increased accountabilities and responsibilities for the nurses. Watson (2005) states “society is in a critical situation today in sustaining human caring ideals and a caring ideology in practice” (p. 19).
Unfortunately, many people in today’s fast paced society never take the time to contemplate their own mortality until they or a loved one become seriously ill and end up in the healthcare arena. This includes some healthcare providers. Nurses must be aware of this.
Inference/Implications/Consequences
Nurses need to set the example. Over the years, many parents have advised their children to get to know themselves before they start in a relationship with the logic being that you have to have yourself before you can share yourself with anyone else. We need to have an understanding ofwho we are, where we’ve been, lessons learned along the way, and the practical application of them. This is true of nursing. Nurses need to set the example. The implications and ramifications of self-care are explained by Watson (2005) who states:
Our ability to sustain our caring ideal and ideology in practice will affect the human development of civilization and determine the health profession’s contribution to society; as a beginning we have to impose our own will to care and love upon our own behavior and not on others. We have to treat ourselves with gentleness, loving kindness, equanimity, and dignity before we can respect and care for others with gentleness, kindness, equanimity, and dignity (p.19).
In their time of need patients and their loved ones look to the nurse. Nursing is continuously evolving. Advances in technology coupled with fiscal reality have resulted in increased demands on nurses. Clukey, Hayes, Merrill, & Curtis (2009) found that “appearing hurried and abrupt was noted as a behavior that was not caring” (p.73). Body language can speak volumes. Today’s nurse must understand this. Merrill, Hayes, Clukey, & Curtis (2012) state, “Caring is the heart and artistry of nursing so understanding what actions, attitudes, and behaviors convey caring is essential to good practice” (p.36).
Today’s nurse must be cognitiveof what they are doing and how they are doing it. The intent and perception of actions can cause misunderstanding. Nurses must not only be aware of transcultural differences and needs, they need to incorporate it into their practice. Body language which can be interpreted to mean different things in different cultures, often speaks louder than words. Vance (2003) states “the top ten caring behaviors, derived from nursing literature, are: attentive listening, touch, comforting, sensitivity, honesty, respect, patience, responsibility, providing information so the patient can make an informed decision, and calling the patient by name” (para. 4). While these seem like relatively simple things, it is often the simple things that get over looked – even though they arguably matter the most. Clukey, Hayes, Merrill, & Curtis (2009) found that “the dominant behavior identified as being caring was explaining what was going on and interpreting medical jargon” (p.73).
Patient satisfaction matters. Nurses must care for the whole patient. This includes providing for spiritual care. Wall, Engelberg, Gries, Glavan, & Curtis (2007) conducted a cross-sectional study to assess what effects family satisfaction with spiritual care provided at end of life in the Intensive Care Unit. The researchers found that families were more satisfied when clergy was involved in the last 24 hours of the patient’s life. They also recommended that care providers “assess spiritual needs sooner than later” and that “further research should be conducted” (p. 1090).
Many nurses are uncomfortable with spiritual care. We need to embrace our theorists: Leininger‘s transcultural teachings and Watson’s Transpersonal Caring to provide and care for Maslow’s needs. Weiland (2010) states:
Nurses report feeling confused and uncomfortable providing spiritual care. In part, this dilemma stems from lack of education, knowledge, and confidence in assessing the spiritual domain. The outcome is that patients may not receive the spiritual care they need at a time when they are most vulnerable, feeling loss, separation from the world, and powerlessness. Thus, ignoring the spiritual dimension of care may impede drawing upon a powerful inner source of strength and hope – it could also be construed as unethical (p. 283-4).
Addressing and providing spiritual care does not have to be scary. Lundberg & Kerdonfag (2010) conducted an explorative qualitative study to explore how Thai critical care nurses provided spiritual care to their patients. The researchers found that “the nurses identified presencing, supporting and encouraging religion, communication, and education as providing spiritual care”. The researchers concluded that “spiritual care is important to meet patients’ needs and nurses should be educated to provide spiritual care” (Lundberg & Kerdonfag, 2010).
The take away is seemingly simple: include, acknowledge, explain things to, and communicate with both patients and their loved ones and families. Nurses must remember presencing and active listening are very effective spiritual interventions. Nurses must care for the whole patient and failure to do so can be construed as unethical and potentially neglectful.
Recommendations for Quality and Safety Improvements
Quality and safety are major issues in healthcare. In fact healthcare itself is a major issue. The growing and aging population is placing increased demands on the healthcare system that is already struggling to accommodateincreased abilities with stretched resources in the face of both nursing and physician shortages. This is all taking place in the setting of a struggling national and global economy. Healthcare facilities are stressed.
Healthcare is an important issue. To better understand some current trends in both healthcare and nursing we must have a working knowledge of a couple major players. It is important that we know about the Robert Wood Johnson Foundation [RWJF] and the Institute of Medicine of the National Academies [IOM].
Robert Wood Johnson was one of the founding brothers of the Johnson & Johnson Company. His son Robert Wood Johnson II founded theRWJF. It is the largest the nation's largest philanthropy devoted solely to the public's health(RWJF website, 2013). “The IOM is an independent, nonprofit organization thatworks outside of government to provide unbiased and authoritative advice to decision makers and the public” (IOM, 2012, para. 1).
The American Nurses Association [ANA] is nursing’s main organization. The ANA (2004) informs us that “in 1999 the IOM described the nation’s healthcare system as fractured, prone to errors, and detrimental to safe patient care” and in 2001 “the IOM identified six aims for improvement so that the healthcare system is: safe, effective, patient centered, timely, efficient, and equitable” (p.19). In 2002, the ANA (2004) states:
If problems in the work environment are not addressed, nurses will not be able to sufficiently protect patients. The impact of nursing staffing upon patient safety has been clearly demonstrated (Needleman & Buerhaus, 2003). The healthcare industry must address the adverse effects on nurses and patient safety of inadequate staffing, healthcare errors, episodes of failure to rescue, and the looming nursing shortage (p.20).
The RWJFresponded to the ANA. The RWJF funded the Quality and SafetyEducation for Nurses [QSEN]Initiative. QSEN(n.d.) states:
Using the Institute of Medicine (2003) competencies for nursing, QSEN faculty have defined pre-licensure and graduate quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency: Patient-Centered Care, Teamwork & Collaboration, Evidence Based Practice, Quality Improvement, Safety, & Informatics(QSEN Institute website, para. 1).