10.

1177/0898010102250274
JOURNAL
Schaefer / AN
OF HOLISTIC
ANALYSISNURSING
OF CARING
/March
BEHAVIORS
2003

Caring Behaviors of Advanced

Practice Nursing Students

Karen Moore Schaefer, R.N., D.N.Sc.

Temple University

The purpose of this project was to provide advanced practice nursing (APN) students
with the opportunity to enrich their aesthetic knowing and acquire the meaning of
caring in their practice by reflecting on their caring narratives. Students were asked
to write about a caring encounter they experienced in their practice. The instructor
analyzed and organized that data from each narrative. The instructor shared the data
with the students for reflection and discussion. This report focuses on the caring prac-
tices of the APN students. Nine themes that embraced physical care, communication,
comfort, presence, knowing, acceptance, touch, collaboration, and encouragement
were identified. The APN students demonstrated aesthetic knowing as well as other
ways of knowing in their caring narratives. Through reflection on the caring experi-
ences and discussion in class, students were able to identify the meaning of caring in
their practice.

Keywords: caring; knowing; presence; comfort; advanced practice

Discussions about caring generate tremendous debate (Eriksson,

2002; Paley, 2001, Skott, 2001; Smith, 1999). These debates center on
whether caring is the essence of nursing (Leininger, 1988) and if

AUTHOR’S NOTE: The author acknowledges Vanessa Jury Harris, B.A., B.S.N., who
was a senior nursing student at Temple University while working on this project, for
her assistance in the coding and validation of the caring themes identified in the
advanced practice nursing students’ narratives of caring. The author also thanks the
Temple University Department of Nursing Research Committee for providing the
funds to analyze and validate the data.
JOURNAL OF HOLISTIC NURSING, Vol. 21 No. 1, March 2003 36-51
DOI: 10.1177/0898010102250274
© 2003 American Holistic Nurses’ Association

36

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Schaefer / AN ANALYSIS OF CARING BEHAVIORS 37

caring defines nursing (Morse, Bottorff, Neander, & Solberg, 1991;

Nelson, 1992; Robinson, 1992). Even with this debate, nurses believe
that caring is part of what they do (Benner, 1990). In an attempt to fur-
ther understand the caring experience, five groups of students in a
graduate nursing course were invited to participate in an interactive
experience on caring. The purpose of the project was to provide stu-
dents with the opportunity to reflect on their caring encounters, to
enhance their aesthetic knowing, and to acquire the meaning of caring
in their practice. This project is significant because it is one the few
reports that focuses on the caring practices as described by advanced
practice nursing (APN) students. APN students involved in this pro-
ject were professional nurses studying for their master’s degree in
nursing.

BACKGROUND

The current literature indicates that caring involves relationships

and showing compassion and feeling for others; guides ethical deci-
sion making; is a human expression of respect for another; and is a
way of relating through mutual trust while experiencing a transfor-
mation of a relationship (Mayeroff, 1971; Swanson, 1999). Watson
(1989) described caring as a human science. According to her, caring is
an absolute value and a way of being. From a transpersonal perspec-
tive, Watson supported the idea that caring embraces a spiritual pro-
cess concerned with preserving human dignity and restoring human-
ity. Minick (1995) found that the stories shared by critical care nurses
demonstrated a relationship between knowledge and caring that was
labeled making the connection. In those situations in which caring did
not occur, the connection was missed.
Caring means connecting with patients by listening to their
thoughts and fears and communicating concern (Bertero, 1999). Car-
ing is more than being just physically present for patients. Caring
involves a commitment to substance and scholarship as well as love
and tenderness (Eriksson, 2002). Caring means giving time and being
available to patients and kin. Wolf and colleagues (1998) found that
nurses’ caring was significantly related to patient satisfaction. The
project reported here was planned to provide APN students the
opportunity to discuss their perceptions and understanding of caring
in preparation for their leadership role as expert practitioners. The
findings in this report support and enhance knowledge of caring

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38 JOURNAL OF HOLISTIC NURSING /March 2003

practices described by APN through reflection on narratives of stories

of caring encounters in APN.

PROCESS

Caring was one of the concepts examined in a graduate nursing

theory course at a small, religiously affiliated liberal arts college in the
northeastern United States. The instructor used a modification of a
technique developed by Smith (1992) to examine caring narratives.
As part of this technique, 68 students wrote about a single caring
encounter they experienced in their nursing practice. They described
the context or events surrounding the encounter, what happened dur-
ing the encounter (process), and the outcome of the encounter (fulfill-
ment). The instructor encouraged free-form writing and asked the
students to write what they felt was important. Students either wrote
or typed the narratives, which ranged in length from one to three
pages. The goal was for the students to reflect on the phenomenon of
caring as they perceived caring in their practices. Each student gave
verbal permission for the instructor to copy the written narratives and
to use the data for analysis at a later time for possible publication.
The instructor analyzed each encounter using the categories of
context, process, and fulfillment. Gerund statements from the narra-
tives were written on index cards and clustered into the general areas
of context, process, and fulfillment. Context was defined as the events
surrounding the encounter and could include the immediate past and
present. Processes were the gerund statements that captured what the
nursing student was doing or thinking during the encounter. Fulfill-
ment statements were outcome statements.
The instructor categorized the data according to context, caring
practice, and fulfillment themes. For example, caring practice items
included providing comfort and assessing patients. Themes were
then written to capture the essence of the items clustered in the cate-
gory. Each group of students reflected on their experiences and the
experiences shared by their classmates. This gave them the opportu-
nity to discuss the meaning of caring.
Over time, 68 narratives were discussed in the classes. A research
assistant was hired to validate the process of item identification, clus-
tering, and theme development. She independently read, analyzed,
and identified themes in the data after the project was completed
using the criteria established by the instructor (Schaefer, 2002). The

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Schaefer / AN ANALYSIS OF CARING BEHAVIORS 39

instructor and the research assistant agreed on theme identification

through an in-depth discussion. To maintain confidentiality, the stu-
dents’ names were cut from the top of the pages and all narratives
were coded. The Institutional Review Board considered this study
exempt because it was part of classroom teaching.

FINDINGS

The instructor found that caring occurred within a relationship

that was often embodied with intense suffering (Schaefer, 2002). The
majority of these encounters involved patients and families who were
seriously ill and experiencing life change. Other categories included
patients and families who experienced severe emotional turmoil and
patients and families who required short-term, episodic care. Patients
who were dying and their families displayed intense suffering. A
male patient with HIV/AIDS who lacked the basic essentials of life
represented short-term, episodic care. A woman with respiratory fail-
ure who was caring for her husband with Alzheimer’s disease repre-
sented emotional turmoil. Caring occurred in contexts that supported
the reciprocal nature of caring (Eriksson, 2002), meaning that all car-
ing examples occurred in a relationship that resulted in a response for
clients and caregivers.
A total of nine major caring themes were identified (see Table 1).
Each caring theme is discussed with some examples from the narra-
tive encounters to provide greater insight to meaning.

Physical care provides an opportunity to assess and monitor patients’

responses to illness and treatment. Physical care provided nurses with
the means to offer caring and the opportunity to act on their ability to
care. A 19-year-old college student experiencing emotional with-
drawal and the stress of being a freshman in college was transferred
from a mental health unit to an intensive care unit. The young
woman’s condition deteriorated rapidly during her first 24 hours in
the intensive care unit. The APN student explained,
My caring was to replace the patient with the daughter and to return
some familiarity to the person these parents loved . . . [The mother] ex-
plained how important her daughter’s looks and neatness were to her
and her boyfriend. From this time on, I shaved her legs and underarms,
painted her fingernails and toenails in the color she preferred . . . I

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40 JOURNAL OF HOLISTIC NURSING /March 2003

TABLE 1
Caring Themes

Physical care provides an opportunity to assess and monitor patients’ responses

to illness and treatment.
Communicating with patients and families empowers them in difficult, complex
situations.
Providing comfort and support creates a sense of calm.
Being present provides time for the caring process to unfold.
Knowing improves the quality of patient care.
Giving unconditional acceptance and graciousness shows respect for human dignity.
Touching expresses concern and commitment.
Working with others involves coordinating activities using a collaborative approach
to care.
Providing encouragement helps patients and families to deal with the ravages of
suffering.

creamed her body with lotion brought from home . . . The outcome was
shared support and hope for recovery between the parents and myself.

Physical care in this case served as a means of caring for the patient
and the family and of creating a sense of physical normalcy for the
student.
In many cases, APN students provided physical care to assess
patients’ responses to illness. For example, changes in vital signs sug-
gested that death was near for a young woman with AIDS and that a
child needed relief from discomfort.

Communicating with patients and families empowers them in difficult,

complex situations. Communicating included health teaching, giving
information, talking with patients and families, and providing emo-
tional support. Many of the APN students’ stories indicated they
spent a lot of time assisting with care decisions, explaining activities,
reviewing procedures, preparing patients and families for the out-
comes of care and treatment, and listening to concerns.
One APN student discussed an encounter with a 29-year-old
woman who experienced a drug overdose and was on a ventilator.
The woman had a 7-year-old daughter and was in the process of seek-
ing a divorce from her husband. The woman’s parents were provid-
ing care for their granddaughter and stayed with their daughter in the
hospital. The APN student said,

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Schaefer / AN ANALYSIS OF CARING BEHAVIORS 41

It was my obligation as well as my choice to spend time with this family

discussing what would happen if the ventilator was to be discontinued,
what brain death meant, whether or not the granddaughter should see
the mother, as well as explaining that nothing could be done until the
husband and the lawyers involved in the case were contacted.

The family understood the need to contact the husband because he

was the legal next of kin. The family decided not to let their grand-
daughter see her mother. They made their peace with their daughter
at her bedside.
Another APN student described caring for an 88-year-old man
who was diagnosed with prostate cancer and dementia. Because of
his intermittent confusion, the APN student was not sure if he could
understand her. She said,

I spoke with him as if he could understand me; I spoke with him as if his
cognitive ability was the same as mine. I told him about my frustration
with his case. I asked him, as I always had, if there was anything he
needed or anything he could tell me to help him and [I would] try my
best to make him comfortable. After no response, I began to [explain
that] when he was able, he could have out-patient treatment. His eyes
widened immediately, and I will never forget the instant that I saw life
in him again. He began to ask many questions. Then he finally stated,
“I’m not hopeless.”

The patient explained that when he had heard the word cancer in
another hospital, he gave up. The current staff members incorrectly
assumed that he was told about his treatment options at the other
hospital.
The APN students heard stories about patients and families and
about family members’ sorrows and thoughts about their ill relatives.
One APN student provided care for a patient with adult respiratory
distress syndrome who was separated from his wife for the first time
in 60 years. The student wrote that she “listened as they verbalized
their wishes for the patient. By the end of the week, a ‘terminal wean’
was in progress and comfort measures only were instituted.” In this
case, listening helped the family make decisions through validation
and acceptance by the APN student.

Providing comfort and support creates a sense of calm. One APN stu-
dent caring for a 7-year-old with brain tumors talked about cuddling
the child and telling him that it was okay to be scared. “He responded
by giving me the biggest and best hug I have ever received.” The

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42 JOURNAL OF HOLISTIC NURSING /March 2003

young boy relaxed, was able to breathe with greater ease, and blew a
kiss to her as she left his home.
Another APN student was somewhat annoyed about the call she
received at work from a former patient whom she did not know. She
felt relief when she returned the call and there was no answer. “At
least I tried to call.” For some reason, she was not satisfied with her ef-
forts and called again. She learned that the man needed help with his
wife who had diabetes because she was recovering poorly after a re-
cent stroke. She explained that she could not help him, and then she

offered to contact some of my colleagues to seek their opinion. The man

was ecstatic; I was careful not to give him false hope. He said he realized
that, but he was touched that I cared to do that for him, especially since I
didn’t know him. It was decided that he would call me back in 2 days to
check my progress. I had the information for him, and I feel better now
because I feel I did my best.

Although struggling with what she needed to do, this APN student
fulfilled her desire to give to others, an altruistic virtue of caring, and
honored her intuitive sense that she needed to reach out to another.

Being present provides time for the caring process to unfold. Presence
may be interpreted by some as being an antecedent or being necessary
for care to occur. Whether presence is physical presence or spiritual
presence is not clear. In this project, presence was identified as an
intervention and involved a temporal component in that it required
real or delayed time. Real time is the time measured by a clock while
with clients. Delayed time is the promise to come back to patients. As
a promise, it is ethical to help patients, as did the APN student who
initially decided not to return a call to a man she did not know.
While one APN student spent time with the family of a dying
patient from Syria, she said that she “could feel a caring presence
enveloping us. I know that presence . . . allowed them to grieve in a
way that was consistent with their culture, not some ‘Americanized’
standard of not allowing emotion to get out of control.”
A second APN student cared for an older woman who was dying
as a result of a massive stroke. The family requested a Do Not Resusci-
tate order. She said,

Very late into the night, it became obvious that this lady was going to
die. I remained at her bedside, speaking softly and holding her hand
until death. During this time, at least two other nurses came in and

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Schaefer / AN ANALYSIS OF CARING BEHAVIORS 43

asked me why I was remaining at her bedside. They thought I should

go out to the nurses’ station with them and watch her monitor. I ex-
plained that I do not believe in allowing a patient to die alone, and I
wanted to be with her. After her death, her family came in and I re-
mained with them. One daughter was extremely grief stricken and
cried, “You promised to wait for me to come back!” While one of the
other nurses was there with me, this daughter asked me if her mother
had any pain before dying and if anyone was with her. I knew I could
honestly answer these questions, and I knew from her demeanor that I
gave her some degree of comfort. . . . I know the lady’s family appreci-
ated my presence.

This APN student stayed with the patient because of her commitment
to providing care through the dying process. She provided presence
without harm and was able to give the family some true comfort.
On the other hand, one APN noted that because she did not take
the time to be present, she was unable to get to know the patient. She
could not care for the patient because she was not “fully present.”

Knowing improves the of quality patient care. Knowing is more than

but not necessarily other than cognitive knowing. The family of a Syr-
ian patient initially responded to the APN student’s caring behaviors
with anger and fear. As soon as she approached the family, she knew
there had to be “more to the story” than the night nurse had shared
with her in morning report. She worked very hard with the family to
learn what was upsetting them and to learn about their beliefs and
practices regarding illness. She was later welcomed as a member of
their family, a gesture that is not literal but says “thank you for caring
for us.”
Another APN student shared her experience of caring for a 38-
year-old mother who was infected with HIV and was showing signs
of full-blown AIDS. The APN student’s task was to help the woman
learn how to give antibiotics to herself.

Throughout the summer, [her] condition deteriorated. She was unable

to see or hear. She no longer was able to go up and down stairs. She was
losing her battle with the awful disease. I knew she was dying and
wanted to transfer her to hospice care. I knew they would be able to
provide her with the support and time she needed. She was stubborn
and refused, stating that she was used to home care and me. She did not
want another person in her home. [She] was lying on the couch unable
to get up, unable to feed herself. She had been a [Do Not Resuscitate].
Her vital signs were low; I knew the end was very near. As I was leav-
ing, she got a burst of energy and called me back to her side, gave me a

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44 JOURNAL OF HOLISTIC NURSING /March 2003

hug and said goodbye to me. Those were the last words this woman
said to me. She survived the weekend. When I saw her on Monday, I
could not believe she was still alive. I could not obtain a blood pressure,
her heart rate was in the 40-50s, and respirations were 8-10. I stayed
with the family for a period of time. They showed me old photos of her.
Finally, on Tuesday, she died.

In both situations, the knowing through attentiveness to the patients

and their families helped maintain the connections that foster caring.

Giving unconditional acceptance and graciousness shows respect for

human dignity. Little acts of kindness, expressions of honesty, accept-
ing individuals without judgment, and maintaining personhood are
all part of preserving human dignity through unconditional accep-
tance and graciousness. Examples of unconditional acceptance and
graciousness included a simple “goodbye,” a statement about “how
beautiful his daughter was,” and demonstrated caring through
efforts to make a patient a person through careful manicuring and
crimping. Acts of kindness, perhaps metaphorically called “my
favorite things,” included singing songs, bringing in favorite toys,
buying a chocolate cupcake, playing the patient’s favorite classical
music, and reading stories. One APN student talked about her non-
judgmental approach to caring for a woman who had a vaginectomy
for recurrent cancer. She said,
I felt close to her. I was able to empathize with all she had gone through
because of my [gynecology] background. I offered her someone who
would listen and accept whatever she had to say nonjudgmentally. We
developed a rapport, which allowed her to share her feelings and
thoughts, including her fears and frustrations. . . . This was not a single
caring encounter but a caring encounter over time. . . . The relationship
involved not only caring but trust and respect, which were reciprocal.
We were honest with each other and allowed each other the freedom to
be just who we were—“no strings attached.”

Another APN student, working as a school nurse, attended to an

agitated adolescent boy. With her interventions, the adolescent be-
came relaxed. He

was provided with reassurance, encouragement for change, teaching

in the area of anger management, and medication regime. He was ac-
cepted for who he was and not compared with other students. He was
provided with a safe atmosphere to calm down and discuss his

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Schaefer / AN ANALYSIS OF CARING BEHAVIORS 45

needs . . . He also felt safe in knowing that he had a place to go when he

felt overwhelmed, instead of acting out in class.

Touching expresses concern and commitment. Physically touching

patients and families expressed concern and commitment and pro-
vided comfort. The students talked about hugging patients and fami-
lies in times of stress, disappointment, death, and joy. Physical touch
provided an intervention that strengthened the integrity of patients
and families. The small boy, who was cradled by his nurse, relaxed,
and his respiratory rate decreased. Another APN student talked
about how the family of a patient who died hugged each other and
her. They thanked her for allowing their loved on to die with dignity,
as she would have wanted.
Another APN noticed a man sitting in his car in the parking lot,
apparently staring at nothing. When he turned out to be her first
patient of the day, she learned that his wife had died 3 days before.
The student listened quietly as he told his story and talked about his
love for his wife. This was the first time he was able to talk about his
loss. The patient and the APN student hugged and cried together. The
APN student said, “It made me realize how important it is to lis-
ten . . . and how they can teach you about love.” She ended by saying
that “in his eyes, [I] saw a silent yet powerful [message].”

Working with others involves coordinating activities using a collabora-

tive approach to care. The APN students in this study talked about initi-
ating multidisciplinary meetings to discuss patients’ care. They con-
sulted with physicians and social workers to assure that all possible
care was being provided, invited a lawyer to represent a family in
end-of-life decisions, and called the clergy to help comfort patients
and families. One APN student caring for a terminal infant coordi-
nated a meeting with the mother, social worker, neonatologist, and
herself to discuss the infant’s care.
Another APN student expressed her concern for a client, who was
a heroin addict, about his lack of heat, food, and electricity. With his
permission, she contacted the gas and electric company to arrange for
power, arranged for food from the food bank, and notified his physi-
cian of his symptoms. She recalled not being happy about spending
more time with him than expected. However, she felt she needed to
safeguard the patient against harm. She said,

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46 JOURNAL OF HOLISTIC NURSING /March 2003

I was surprised at the end of the visit; [he] said to me, ‘Thank you for
helping me. You’re the first medical person who hasn’t treated me like
dirt because I am an addict. You’ve given me hope. Maybe I can change
after all.

Caring fulfilled a universal nursing goal of providing physical and

emotional comfort while promoting patient safety. She respected and
appreciated him as a human being.

Providing encouragement helps patients and families to deal with the rav-
ages of suffering. One APN student spent a great deal of time working
with a mother to help her understand the situation her new infant
faced. Although the baby was compromised at birth, the mother was
very excited about the birth of her fourth daughter and talked about
the baby’s personal characteristics. The baby progressed poorly, did
not cry, and had very little movement. The APN student said,
As I observed mom and baby, I felt torn between allowing mom to enjoy
her infant and hope for the best and presenting mom with an honest
outlook. I described the infant from head to toe, pointing out to mom
characteristics that were normal and characteristics, such as the baby’s
[muscle] tone, that were of concern to me. . . . I remember saying to the
mother that developmentally, we were not concerned about when the
baby would learn to suck, swallow, or crawl but if she would ever reach
developmental milestones. . . .We allowed mom to make the decision of
whether or not to resuscitate the baby. [She] said she understood what
we said but would provide whatever care her infant needed for how-
ever long she needed it.

Without providing false hope, the APN student helped the mother to
see the challenges her infant faced and was willing to provide support
for whatever decision the mother made. Ultimately, she made an in-
formed choice about her daughter’s care.

REFLECTION

Nursing’s mission is to help those who suffer (Eriksson, 2002). Car-

ing involves connecting with others to facilitate understanding. This
understanding may result in hope, the feeling of being valued and
loved, and an increased sense of well-being. It is through the connec-
tions that nurses understand and reduce suffering.
The findings of this project offer rich data that help to validate and
expand developing theories on caring in nursing (Beck, 2001;

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Schaefer / AN ANALYSIS OF CARING BEHAVIORS 47

Eriksson, 2002; Smith, 1999; Sumner, 2001; Swanson, 1999). The find-
ings also suggest that caring is present in the art (creative use of sci-
ence) and the science (knowledge) of nursing (Leight, 2002). In addi-
tion, the APN students speak to the ethics (obligations) and values
(respect and unconditional acceptance) of caring.
The art of nursing comes alive when students are invited to write
narratives of their caring encounters. The art is evident when APN
students provide personal care to patients that physically makes them
resemble the people they were before their illnesses. The changes in
physical appearance were deliberate transformations to what the
patients would be if they could care for themselves. The art of nursing
represents aesthetic knowing in practice (Leight, 2002).
The science of nursing is evident when the APN student interprets
the meaning of signs and symptoms. One student used this informa-
tion to prepare families for the finality of death, which provided com-
fort to patients and families.
The art and the science of nursing come together when the APN
student combines medical care with knowing the importance of meet-
ing the unique needs of suffering clients. The APN student knows
that preserving human dignity and providing comfort result in a
sense of calm and peace. Caring for others improves patients’ experi-
ences of living and dying.
A purposeful interaction between nurses and patients is necessary
for caring to occur (Sumner, 2001). As the APN students in this study
learned, these relationships require that they know themselves. The
one caring seeks to understand the self to understand others. This
self-devotion enhances mutuality in a caring interaction (Gastmans,
de Casterle, & Schotsmans, 1998), and caring ultimately becomes part
of the relationship. The process of reflecting on caring narratives
helped students to learn more about their styles of caring and, hence,
more about themselves and their patients.
As a result of nurses connecting with patients and families, healing
for patients and families can occur. These connections help to uncover
behaviors, thoughts, and feelings that facilitate understanding of
experiences and promote the development of new nursing knowl-
edge (Schon, 1987). Working with others maximizes the caring experi-
ence and the achievement of mutual respect and provides hope when
all else seems futile and empowerment and understanding in those
who are partners in care.
Vivid presence recognizes reciprocal relationships between unique
individuals. Personal presence assures others of another’s concern for

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48 JOURNAL OF HOLISTIC NURSING /March 2003

their well-being. Full presence occurs when nurses engage in empa-

thetic reciprocal interactions with patients (Cooper, 2001). Being pres-
ent supports Beck’s (2001) findings that presence sets the stage for car-
ing to occur and involves active listening and being sensitive to
others. Presence serves as a means to care and as a caring intervention.
The APN students in this study recognized presence as giving time
and being present. One APN student recognized that caring did not
occur in the absence of presence because she did not take the time to
“know the patient.” By not giving time, she did not get to know the
patient. To be professional nurses, nurses have to “be there.” Once
there, knowledge and creative energies enable APN students to pro-
vide appropriate professional care to their patients.
According to Beck (2001), caring involves supporting and giving to
others without expecting anything in return. In this project, uncondi-
tional acceptance and graciousness showed respect for human
beings. This behavior included little acts of kindness, emotional sup-
port, and acceptance of patients’ behaviors with “no strings
attached.”
Being sensitive to patients is one of the top 10 caring activities of
nurse practitioners (Brunton & Beaman, 2000) and is vividly present
when APN students are sensitive to cultural differences in response to
illness. One APN, who was sensitive to the Syerian family’s prefer-
ences, knew that the family needed to be with the patient during all
phases of care. It was important for them to understand the reason for
the care and why “this happened to our father.” This sensitivity, atten-
tion to uniqueness, and particular knowledge are what help makes
the APN caring practice different from that of expert nurses (Oberle &
Allen, 2001).
Other caring behaviors similarly identified by nurse practitioners
(Brunton & Beaman, 2000) and APN students in this study included
listening to patients, showing respect for patients, talking with
patients, being honest with patients, and listening to patients. Valida-
tion of the caring practices of nurses and APN students supports that
caring is a central component of professional nursing.

IMPLICATIONS

Holistic nursing focuses on the interconnectedness of the mind,

body, and spirit (Watson, 1999). To help students and practicing

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Schaefer / AN ANALYSIS OF CARING BEHAVIORS 49

nurses maintain a holistic approach to care, educators can use the

knowledge gained from this and prior studies to help them develop
the art, science, and ethic of nurse caring. It is through the careful
blending of the art, science, and ethic of caring that holistic nursing
becomes evident in practice.
Based on the assumption that caring is what nurses do, the science
of caring can be learned. However, the ethics and virtues of caring are
difficult to teach without application to practice. In practice, behav-
iors can be directly modeled. When not in practice, Leight (2002)
stated that sharing personal stories of caring and reading others’ sto-
ries of caring may help students and professionals to continue to learn
the ethics and virtues of caring. As a result they can use the reflective
process to learn the integration of the science, art, and ethic of nurse
caring.
Educators should continue to study caring processes in the aca-
demic setting, with particular emphasis on the “how” of teaching and
learning caring. Consistent with the need to increase student-
centered learning, students can use reflective journaling to facilitate
learning about their caring styles. Young-Mason (2001) recom-
mended deep reflection to keep the spirit of caring alive at a time
when the health care system could be destructive to the essence of
being in practice.

CONCLUSION

The findings of this project support that caring occurs in a relation-

ship in which people or families seek or require nursing care. The pro-
cess of caring validates the importance of assisting clients to accom-
plish what they are unable to accomplish on their own. The
connections that APN students establish with patients affect their
perceptions of the care they receive. Ultimately, the success of health
care systems in meeting the needs of clients, families, and populations
will depend on the caring provided by professional nurses. If caring is
accepted as the essence of nursing, then caring must continue to be
developed and validated as an art and a science of nursing through
reflective education and practice. Reflection helps APNs to enhance
aesthetic ways of knowing and to define their perceptions of the car-
ing process. With validation, students at all levels will become more
confident practitioners.

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50 JOURNAL OF HOLISTIC NURSING /March 2003

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Karen Moore Schaefer, R.N., D.N.Sc., is an assistant professor for the Department
of Nursing in the College of Allied Health Professionals at Temple University in Phil-
adelphia, Pennsylvania. Her educational research interests include developing criti-
cal thinking skills and reflective practice. Her research program focuses on women
with chronic illnesses, with a particular emphasis on women with fibromyalgia.

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