Chapter 25

NURSING AS AN ART CARING

In our present set up for health care delivery system, technology is highly
appraised as part of management and caring skills are sometimes
neglected.

 Caring is a dimension of human relating, and often referred to as the art

of caring.
 Smith ( 2013) proposes that nursing cannot exist without caring. Caring
is central to all professions, and enables people to create meaning in
their lives.
 Caring is sharing deep and genuine concern about the welfare of
another person.
PROFESSIONALIZATION OF CARING

 Caring Practice involves connection, mutual recognition, and involvement between nurse and client:

Situations of Caring: Example

 A client experiencing postoperative pain is given medication to control her symptoms, and then the
nurse talks quietly and holds her hand for a few minutes as the pain resolves. The nurse presence, in
itself, provides comfort for the client.
 After the student nurse washes the hair of an older woman who is immobilized and applies her make
up, she helps the woman into a wheelchair to greet her daughter and grandchildren. The woman is
extremely grateful and her sense of dignity is enhanced by this personal care.

 If clients benefit from caring practices, the nurses involved in these situations experience caring
through knowing that they have made a difference in their lives.
 The ability to give clients focused attention means leaving the egocentric self behind.
CARING as “Helping the Other Grow”

Milton Mayeroff ( 1990 ), a noted philosopher, has

proposed that to care for another person is to help him
grow and actualize himself. Caring is a process that
develops overtime, resulting in deepening and
transformation of the relationship. Recognizing the other
as having potential and the need to grow, the caregiver
does not impose direction, but allows the direction of the
other person’s growth to help determine how to respond.
Mayeroof ( 1990 ) defines major ingredients of caring that provide structure and further
description of this process:
a. Knowing- means understanding the other needs and how to respond to these needs;
b. Alternating Rhythms- signifies moving back and forth between the immediate and
long- term meanings of behavior considering the past;
c. Patience- enables the other to grow in his own way and time;
d. Honesty- includes awareness and openness to one’s own feeling and a genuineness in
caring for the other.
e. Trust- involves letting go, to allow the other to grow in his own way and own time.
f. Humility – means acknowledging that there is always more to learn, and that learning
may come from any source;
g. Hope –is belief in the possibilities of the other’s growth
h. Courage – is the sense of going into the unknown, informed by insight from past
experiences
PROGNOSIS
Mayeroof ( 1990 ) proposes that the caring process
has the benefits for the one giving care. By helping
the other person grow, the caregiver moves toward
self-actualization. By caring and being cared for,
each person “finds his place” in the world. By
serving others through caring, individuals live the
meaning of their own lives.
NURSING THEORIES ON CARING

 Caring is at the heart of nursing’s identity; indeed, the root of the word nursing means
“nurturance” or “care”. ( Smith, 2013 )
 Theorists on CARING:
1. Leininger
2. Ray
3. Roach
4. Boykin
5. Schoenhofer
6. Watson
7. Swanson
Culture Care Diversity and Universality (MADELEINE LEINIGER )

 Leininger emphasizes care as a “distinct, dominant, unifying, and central focus of nursing”.
( George, 2011, p. 406). Her theory of culture care diversity and universality is based on the
assumption that nurses must understand different cultures in order to function effectively.
 To provide care that is congruent with cultural values, beliefs, and practices, the nurse must
understand these differences and similarities.
 To understand the care desired by clients, the nurse requires knowledge of the culture and local
language.
 When nursing fails to be reasonably congruent with the client’s beliefs, lifeways, and values, signs
of conflict, non-compliance, and stress may arise.
 Culturally congruent care involves 3 action-decision care approaches:
1. preservation of the client’s familiar lifeways
2. accommodations that help client adapt to or negotiate for satisfying care
3. repatterning nursing care to help the client move toward wellness.
 Leininger further defines caring as “assistive, supportive, and enabling experiences or ideas
towards others with evident or anticipated needs, to ameliorate or improve a human condition or
lifeway” ( George, 2011, p. 406 )
THEORY OF BUREAUCRATIC CARING ( DR. MARILYN RAY )

 Ray’s theory of bureaucratic caring focuses on caring in organizations ( e.g. hospitals ) as

cultures.
 Nursing is holistic, relational, spiritual, and ethical caring that seeks the good of self and others
in complex community, organizational, and bureaucratic cultures. Dwelling more deeply with the
nature of caring reveals that the foundation of spiritual caring is love. Through knowledge of the
inner mystery of the inspirational life within, love calls forth a responsible ethical life that
enables the expression of concrete actions of caring in the lives of nurses. As such, caring is
cultural and social. Transcultural caring encompasses beliefs and values of compassion or love
and justice or fairness, which find significance in the social realm, where relationships are
formed and transformed. Transcultural caring serves as a unique lens through which human
choices are seen, and understanding in health and healing emerges. Thus, through compassion
and justice, nursing strives toward excellence in the activities of caring through the dynamics of
complex cultural contexts of relationships, organizations, and communities (M. Ray, personal
communication, May 25, 2004).
THEORY OF BUREAUCRATIC CARING
THEORY OF BUREAUCRATIC CARING
CARING THE HUMAN MODE OF BEING ( SISTER SIMONE ROACH (1992)

 Roach (1992) discusses how people in healthcare professions care for others not because they are
required to do so by their jobs, but because they are human beings and this trait of caring is intrinsic to all
humans .
 According to Roach (1992) caring is the underlying concept that forms the basis of what nurses do each
and every day.
 Entailed in caring as the human mode of being are:

1. The capacity of the power to care

2. The calling forth of this capacity
3. Responsivity of being called to someone, something who/which matters
4. The actualization of the capacity or the power to care
5. The activity or performance of caring as manifested in specific caring behaviors.
 ATTRIBUTES OF
CARING

There is now an additional attribute of caring, according to “ Nursing- a World of

Caring” which is CREATIVITY.
Compassion

Compassion means to be with another in their suffering. It is

empathy and sensitivity to human pain and joy that allows one
to enter into the experience of another. It is the understanding
of whom that person truly is for whom one is caring. According
to Simone Roach, “With compassion, one becomes a colleague
of humanity” (Roach, 1992). Compassion is an essential
component of the nurse patient relationship.( Summary: Awareness of
one’s relationship to others, sharing their joys, sorrows, pain, and accomplishments.
Participation in the experience of another. )
Competence

Competence is acquiring and using evidence-based scientific and

humanistic knowledge and skill in the application of therapeutic
interventions in the current practice of nursing. Competence is
reflected in the cognitive, affective and psychomotor domains of
learning. It is the knowledge of the role of the nurse in the health care
delivery systems of the hospital and the community. ( Summary: Having the
knowledge, , judgment, skills, energy, experience and motivation required to respond adequately to
the demands of one’s professional responsibilities.)
Conscience

Conscience directs moral, ethical and legal decision-making. It motivates us to

increase the knowledge and skills needed to respond appropriately to moral, ethical
and legal issues faced by one and others. It directs us to adhere to the standards of
professional nursing practice. It directs us to respond to social injustices. It is the
increased awareness of local, national and global health concerns and current trends
in health care that affect all ages and populations. It is the sense of accountability,
responsibility and leadership for patient care. ( Summary: Morals, ethics, and an informed
sense of what is right and wrong. Awareness of personal responsibility. )
Confidence

Confidence is trust in one’s ability to care for others. It is the belief that our skilled,
professional presence can make a difference. Confidence is necessary to effectively
implement the roles of the nurse as caregiver, teacher, counsellor, advocate, leader,
manager and researcher. Confidence in our own ability to create caring environments
serves as a catalyst for change. Confidence empowers both us and others to define and
accomplish goals. Confidence is developed through the successful utilization of
knowledge and experience. ( Summary: Comfort with self, client, and others that allows one to
build trusting relationships.)
Commitment

Commitment is maintaining and elevating the standards and obligations of the

nursing profession and assuring the delivery of excellence in nursing care.
Commitment is the loyal endeavor to devote ourselves to the welfare of patients. It
assures that caring will be part of every nurse patient interaction. It is a conscious
effort to grow within the nursing profession through dedication to continuing
education, life-long learning, and becoming more skilled, socially conscious, ethical,
politically competent and caring. ( Summary: The deliberate choice to act in accordance with
one’s desires as well as obligations, resulting in investment of self in a task or cause.)
Comportment

Comportment is the professional presentation of us as nurses to others in behavior,

attitude, appearance, dress and language that communicate a caring presence. It
includes the need for self-awareness, awareness of impact of self on others, and
accepting responsibility for our actions. This extends to responsibility for the
healthcare environment and the behavior of others who contribute to it. ( Summary:
Appropriate bearing, demeanor, dress, language that are in harmony with a caring presence. Presenting
oneself as some one who respects others and demand respects. )
Creativity

Creativity is having a vision of how nursing care can be, and making it better.
Creativity in nursing requires thinking reflectively, critically and imaginatively to
create healing environments and enhance care-giving practices. It requires the
nurse to develop the qualities of envisioning, risk-taking, openness and
resourcefulness. Creativity results in integrating new insights into existing nursing
knowledge and awareness. It creates the potential for the nurse to individualize
care and embrace change.
Application and Significance of Caring in Nursing according to Roach

Caring is the core and basic foundation for nursing practice. (skills,
techniques, specialized language are the trim)

Caring is the vehicle through which nurses interact with patients and assist them
to cope with suffering, to find meaning in their experiences, to promote health
and wellness and to die with dignity.

Caring is action that nurtures; action that fosters growth, recovery, health and
protection of those who are vulnerable. Caring is the empowering of those for
whom care is given (Roach, 1997).

Caring is the framework through which we as nurses implement the art and
science of professional practice.
NURSING AS CARING (ANNE BOYKIN and SAVINA SHOENHOFER )

 Analysis and Evaluation of the theory’s assumptions, values, concepts and propositions: “Caring is the
end rather than the means of nursing, caring is the intention of nursing, rather than an instrument.”
(Parker & Smith p 371)

 Persons are caring by virtue of their humanness. The three strengths of humanity being love, kindness
and social intelligence. Nursing as a profession uniquely focuses on caring as it’s central value, its
primary interest and direct intention for practice.

 Persons are whole and complete in the moment. The foundational values of respect and coming to
know grounded the theory and revolves around the theme of responding to what matters. Caring
means spiritual commitment and devotion inspired by the love and respect for persons as a whole.
(Boykin & Schoenhofer, 2001, p 393

 Personhood is a way of living grounded in caring. Personhood is living life grounded in caring One’s
personhood is enhanced by participating in nurturing relationships with caring others. It is one’s living
out of who they are in congruence with their beliefs and behaviors and living the meaning of one’s
life.
 Nursing is both a discipline and a profession. A call for nursing is a call for acknowledgement and
affirmation of the person living caring in specific ways in the immediate situation. It is a call for
nurturance. Nurses develop sensitivity and expertise in hearing calls through intention,
experience, study and reflection in a broad range of human situations. (Parker & Smith 373)

 The Theory in relation to Practice Nurturing persons living caring and growing in nursing is the
nurses’ commitment to practice nursing as caring. It is often challenged when nurses are
presented with someone who is difficult to care and it is in this situation that the nurse uses all
available patterns of knowing, grounded in the obligations and intentions inherent in the
commitment to caring: the knowledge of self and others, empirical, aesthetic and ethical
knowing.

 From the perspective of the theory of nursing as caring, the nurse approaches each client as a
caring person, whole and complete in the moment. The idea of wholeness includes
understanding that people are not perfect, but constantly growing and changing. By living
nursing as caring, the nurse establishes a mutual relationship of trust and respect with the client.
Through fully appreciating the life world of others, the nurse energizes self and others to grow as
caring individuals
THEORY OF HUMAN CARE ( JEAN WATSON)
1. THE FORMATION OF A HUMANISTIC- ALTRUISTIC SYSTEM OF VALUES
Begins developmentally at an early age with values shared with the parents.
Mediated through ones own life experiences, the learning one gains and exposure to the humanities.
Is perceived as necessary to the nurse’s own maturation which then promotes altruistic behavior towards others.

2. FAITH-HOPE
Is essential to both the carative and the curative processes.
When modern science has nothing further to offer the person, the nurse can continue to use faith-hope to provide a
sense of well-being through beliefs which are meaningful to the individual.

3. CULTIVATION OF SENSITIVITY TO ONE’S SELF AND TO OTHERS

Explores the need of the nurse to begin to feel an emotion as it presents itself.
Development of one’s own feeling is needed to interact genuinely and sensitively with others.
Striving to become sensitive, makes the nurse more authentic, which encourages self-growth and self-actualization, in
both the nurse and those with whom the nurse interacts.
The nurses promote health and higher level functioning only when they form person to person relationship.

4. ESTABLISHING A HELPING-TRUST RELATIONSHIP

Strongest tool is the mode of communication, which establishes rapport and caring.
Characteristics needed to in the helping-trust relationship are:
Congruence
Empathy
Warmth
Communication includes verbal, nonverbal and listening in a manner which connotes empathetic understanding.
5. THE EXPRESSION OF FEELINGS, BOTH POSITIVE AND NEGATIVE
“Feelings alter thoughts and behavior, and they need to be considered and allowed for in a caring relationship”.
Awareness of the feelings helps to understand the behavior it engenders.

6. THE SYSTEMATIC USE OF THE SCIENTIFIC PROBLEM-SOLVING METHOD FOR DECISION MAKING
The scientific problem- solving method is the only method that allows for control and prediction, and that permits self-
correction.
The science of caring should not be always neutral and objective.

7. PROMOTION OF INTERPERSONAL TEACHING-LEARNING

The caring nurse must focus on the learning process as much as the teaching process.
Understanding the person’s perception of the situation assist the nurse to prepare a cognitive plan.

8. PROVISION FOR A SUPPORTIVE, PROTECTIVE AND /OR CORRECTIVE MENTAL, PHYSICAL, SOCIO-CULTURAL AND
SPIRITUAL ENVIRONMENT
Watson divides these into eternal and internal variables, which the nurse manipulates in order to provide support and
protection for the person’s mental and physical well-being.
The external and internal environments are interdependent.
Nurse must provide comfort, privacy and safety as a part of this carative factor.
9. ASSISTANCE WITH THE GRATIFICATION OF HUMAN NEEDS
It is based on a hierarchy of need similar to that of the Maslow’s.
Each need is equally important for quality nursing care and the promotion of optimal health.
All the needs deserve to be attended to and valued.

 WATSON’S ORDERING OF NEEDS

Lower order needs (biophysical needs)
The need for food and fluid
The need for elimination
The need for ventilation

 Lower order needs (psychophysical needs)

The need for activity-inactivity
The need for sexuality

 Higher order needs (psychosocial needs)

The need for achievement
The need for affiliation
Higher order need (intrapersonal-interpersonal need)
The need for self-actualization
10. ALLOWANCE FOR EXISTENTIAL-PHENOMENOLOGICAL FORCES

Phenomenology is a way of understanding people from the way things appear to them, from
their frame of reference.

Existential psychology is the study of human existence using phenomenological analysis.

This factor helps the nurse to reconcile and mediate the incongruity of viewing the person
holistically while at the same time attending to the hierarchical ordering of needs.
Thus the nurse assists the person to find the strength or courage to confront life or death.
THE SEVEN ASSUMPTIONS

1. Caring can be effectively demonstrated and practiced only interpersonally.

2. Caring consists of carative factors that result in the satisfaction of certain human
needs.
3. Effective caring promotes health and individual or family growth.
4. Caring responses accept person not only as he or she is now but as what he or she
may become.
5. A caring environment is one that offers the development of potential while allowing
the person to choose the best action for himself or herself at a given point in time.
6. Caring is more “ healthogenic” than is curing. A science of caring is complementary
to the science of curing.
7. The practice of caring is central to nursing.
SOCIAL and ETHICAL RESPONSIBILITIES OF NURSES IN RELATION TO CARING:

1. The nurse must care for the self in order to care for others.
2. Nurses must remain committed to human care ideals.
3. Cultivation of a higher/deeper self and a higher consciousness leads to caring.
4. Human care can only be demonstrated through interpersonal relationship.
5. Honoring the connectedness of all ( unitary consciousness ) leads to transpersonal
caring-healing
6. Education and practice systems must be based on human values and concern for the
welfare of others.
THEORY OF CARING ( KRISTEN SWANSON)

MAJOR CONCEPTS & DEFINITIONS

CARING

Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of
commitment and responsibility (Swanson, 1991).

KNOWING

Knowing is striving to understand the meaning of an event in the life of the other, avoiding
assumptions, focusing on the person cared for, seeking cues, assessing meticulously, and engaging
both the one caring and the one cared for in the process of knowing (Swanson, 1991).

BEING WITH

Being with means being emotionally present to the other. It includes being there in person,
conveying availability, and sharing feelings without burdening the one cared for (Swanson, 1991).
DOING FOR

Doing for means to do for others what one would do for self if at all possible, including
anticipating needs, comforting, performing skillfully and competently, and protecting the one
cared for while preserving his or her dignity (Swanson, 1991).

ENABLING

Enabling is facilitating the other’s passage through life transitions and unfamiliar events by
focusing on the event, informing, explaining, supporting, validating feelings, generating
alternatives, thinking things through, and giving feedback (Swanson, 1991).

MAINTAINING BELIEF

Maintaining belief is sustaining faith in the other’s capacity to get through an event or transition
and face a future with meaning, believing in other’s capacity and holding him or her in high
esteem, maintaining a hope-filled attitude, offering realistic optimism, helping to find meaning,
and standing by the one cared for no matter what the situation (Swanson, 1991).
TYPES OF KNOWLEDGE IN NURSING
EMPIRICAL KNOWING: THE SCIENCE OF NURSING
PERSONAL KNOWING: THE THERAPEUTIC USE OF SELF
ETHICAL KNOWING: THE MORAL COMPONENT
AESTHETIC KNOWING : THE ART OF NURSING
CARING ENCOUNTERS:

1. Knowing the client- who is this person, client’s history, needs

desires, dreams, where is home, who cares?
2. Nursing Presence- partnership between the nurse and client
3. Empowering the client- the nurse is able to identify and build on
client/family strengths, builds mutual respect, trust and confidence
in the other’s abilities and motives. Enabling-coaching, informing,
explaining, guiding, focusing and validating.
4. Compassion – warm, emphatic, compassionate and concerned. “
Walking in his shoes”
5. Competence – employs necessary knowledge, judgment, skills, and
motivation to respond adequately to client’s needs.
MAINTAINING CARING PRACTICE:
1. Caring for self
a. A healthy lifestyle: nutrition, activity, exercise and recreation
b. Mind-body therapies: Guided imagery, meditation, story telling, music therapy, yoga
2. Reflection on Practice
Reflection is thinking from a critical point of view, analyzing why one acted in a certain
way, and assessing the results of one’s action.
Reflective practice- is a method of self-examination that involves thinking back over what
happened in nursing situation. It requires discipline, action, openness and trust.
Use Models of Reflections:
1. What happened
2. What did you do and think
3. What did it mean
4. How do you evaluate the situation
5. What did you learn
6. Now, what

 Positive Affirmations:
Begin the day positively like
“ I am happy to be alive”
Situation:
How will you care for this mother?
Maam Theresa Siko give birth for the first time. Unfortunately, the baby was dead when born. Maam Siko is a
single mother, an Indian by nationality and currently working in a business establishment here in the Phil. She was
alone here in the Phil. The father of the child was a Filipino but did not accept the responsibility to marry Maam
Siko and to be a father of the child. Upon knowing that the child was born dead, Maam Siko really cried and did not
want to eat nor do anything. She did not know what to do also with her dead baby especially now that we have
this pandemic. How will you care as a nurse for the situation of Miss Siko?