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Caring in Nursing

CHERYL LYN A. SANCHEZ RN MAN

Story:
As a nursing student I once cared for a client by the name of Mr. Johnson. He was an older gentleman, who was very ill and non-communicative. He was in the first room to the right past the nursing station. There were few personal belongings in his room, and I never observed visiting family or friends. The room was dark and all I could see and hear was Mr. Johnsons labored breathing through

His tracheostomy and the cyclical clicking of the intravenous pump. Both his legs were immobilized and pinned from feet to the knees. Everytime I would walk into his room I spoke to him, Hi Mr. Johnson, its Danene, your student nurse, Im here to and I would talk to him what I was there to do. When I would turn, bathe, clean his leg pins or suction his trach, I would tell him I hoped he slept well

Last night and what the weather was like that day. I would talk with him in a conversation as though he was returning a dialogue with me. Every now and then he would move or make grunting sound and I began to understand what he needed. Over a couple of hours he told me what was okay for him and he never spoke a word.

The next morning I walked into his room and introduced myself again. I could see the tension in his face fade as his cheeks relaxed. He knew I was there for him. Later that day when the floor nurse came into the room, I was talking to Mr. Johnson as I usually did. She looked at me with disgust and said, he cant hear you and he doesnt talk. I decided to continue my conversations with Mr. Johnson despite the floor nurses disaaproval.

As my shift was ending that day, I told Mr. Johnson that I would be back in the morning bright and early. I held his hand and then gave it a little pat and said, Ill see you in the morningsleep well the next morning I found Mr. Johnsons room empty.

I was told Mr. Johnson died in the early hours of the morning. To this day I will never know if Mr. Johnson actually heard or understood my words but if he did, he knew I was his advocate and someone he could count on. My interactions with Mr. Johnson and the floor nurse forever changed the way I practice nursing. I have relived this experience many times over and would never change a single thing.

--Danene Shannon MS Ed, BSN, BA, RN Professional Clinical Educator/Patient Education Specialist, Advocate Lutheran General Hospital, Park Ridge, II

Meaning of Caring
Number of Definitions People, Relationships, and Things Matter Mayerhoff
Growth and actualization A process Benefits for the one giving care and one receiving care

Caring is Universal
Influences the way people think, feel and act Many nursing theorists have tried to define caring Nightingale was first Caring is the heart of nursing

Meaning of Caring
Major ingredients of caring:
Knowing Alternating rhythms Patience Honesty Trust Humility Hope Courage

Meaning of Caring
Summary of Definitions
Multidimensional concept Five viewpoints
Caring as a moral imperative Caring as an affect Caring as a human trait Caring as an interpersonal relationship Caring as a therapeutic intervention

Types of Knowledge in Nursing


Empirical Knowing

Personal Knowing

Ethical Knowing

Aesthetic Knowing

Types of Knowledge in Nursing


Empirical Knowing
The science of nursing

Aesthetic Knowing
The art of nursing

Personal Knowing
The therapeutic use of self

Ethical Knowing
The moral component

Mayeroffs Caring Ingredients:


1971
Knowing the other; understanding their needs and responding properly; good intentions do not equate to caring Learning from mistakes and modifying behavior in response to another Having patience to allow another to grow in their own time and own way Being honest enough to accept others as they actually are rather than how you wish them to be

Mayeroffs Caring Ingredients


(continued)

Trusting that others have the ability to grow and self actualize in their own time and way Being willing to learn from those you care for Maintaining hope that other will grow through caring Having courage to follow the lead of another into the unknown

Theories of Caring
Theory of Bureaucratic Caring (Ray) Caring is contextual influenced by organizational structure Caring, the Human Mode of Being (Roach) Center of all attributes used to describe nursing Six Cs of caring (see table 1) Nursing as Caring (Boykin and Schoenhofer) Purpose of the discipline and profession of nursing

CONCEPT MAP REFLECTING THE THEORY OF BUREAUCRATIC CARING


technological
educational

physical

SocialCultural

SpiritualEthical Caring

legal

economic

political

THE 6 CS OF CARING IN NURSING


COMPASSION awareness of ones relationship to others, sharing their joys, sorrows, pain, and accomplishments. Participation in the experience of another COMPETENCE having the knowledge, judgment, skills, energy, experience and motivation to respond adequately to others, within the demands of professional responsibilities
CONFIDENCE- the quality that fosters trusting relationships. Comfort with self, client and family. CONSCIENCE morals, ethics and an informed sense of right and wrong. Awareness of personal responsibility. COMMITMENT convergence between ones desires and obligations and the deliberate choice to act in accordance with them COMPORTMENT appropriate bearing demeanor, dress, and language, that are in harmony with a caring presence. Presenting oneself as someone whe respects others and demands respect

Benner (Holistic Theory)


Equates excellent nursing practice with CARING People, events, projects (things) have importance Caring means connectedness or involvement Caring helps patients understand and adjust to illness

Benner, cont.
Defines health as a state of being
Individualized by ones
Values Personality Lifestyle

Treatment for illness is worthless if not applied to the individual

Primacy of Caring (Benner and Wrubel)


Nursing as a relationship Caring is primary Possibility of giving and receiving help

Leininger (Transcultural)
Culture Care Diversity and Universality (Leininger) Understanding culture essential for nursing care Caring is the essence of Nursing it is a distinguishing characteristic Purpose of care is to assist the individual toward improvement in condition Caring is Nurturing Dependent on needs of individual Must reflect the patients own culture

Watson (Transpersonal)
Theory of Human Caring (Watson) Basis for nursings role in society Essence and moral ideal of nursing Holistic Patient, family, environment Nurses exhibit conscious decision to care This helps patient toward healing and wholeness Focus in on cAre, not cUre cAring inner healing health Nurse & patient affected by relationship

Swanson
Caring has 5 dimensions
Knowing Being with Doing for Enabling Maintaing belief

Caring is central to nursing Theory can be applied to clinical setting

Nightingales Caring Arts


Never defined caring Her writings suggest insight into the nature of caring, healing, and health.
Nature was a curing and restorative force. The role of the nurse was to create a healing environment. Stressed the importance of all five senses in promoting health Advocated for restructuring of mental and cognitive thoughts

Caring is Relational
Patients value nurse Effectiveness
Ability to perform tasks

Also value nurse Affect


Attitude or demeanor while performing the tasks

Patients are more willing to participate if they sense that they are cared about

Ethic of Care
Protects human dignity Often perceived as a moral imperative Requires awareness of potential unequality in relationships
This due to either real or perceived power that patient assigns to the nurse Knowledge is power

Expressions of Care
Spiritual
Being aware of & honoring patients beliefs

Presence
Being there
Physically present Demonstrating understanding

Being with
Sharing oneself

Touch
Skin-to-skin Eye contact (nonverbal) Protective to prevent injury

Listening
Taking in patient information Interpreting what has been taken in

Knowing
Understanding the client Understanding the planned interventions Avoid making assumptions Focuses on client

Caring in Practice
Caring encounters are demonstrated by
Knowing the client Nursing presence Empowering the client Compassion Competence

Creating Beauty through Nursing Care


Caring is a way of expressing the beauty of nursing. Caring and art are transformational. The art of nursing is the capacity of a person to receive another persons expression of feelings and to experience those feelings for oneself. Caring, empathy, creative resources, and intuition are examples of nurse artistry.

Conceptualizations of Nursing as Art (Johnson, 1994)


Ability to grasp meaning in patient encounters Ability to establish a meaningful connection with the patient Ability to perform nursing activities skillfully Ability to determine rationally an appropriate course of nursing action Ability to conduct ones nursing morally

Illuminations of Caring in Nursing


Nursing leaders are characterizing caring as an essential moral value. Nursing students are not taught to care; they care because they are individuals. The ability to exercise and express caring is influenced by many factors. Technology and science used as substitutes for human caring dehumanize.

Actions to Make Caring Visible


Be more responsive to societal needs. Be more compassionate and successful in humanizing the highly technological health care environment. Make insightful decisions regarding ethical issues. Be a capable and creative critical thinker. Become knowledgeable regarding cultural diversity while providing culturally sensitive care. Become politically active on behalf of the health needs of all individuals. Become a better prepared nurse for the professional roles of nurses in the future.

Caring and Service


Many nurses indicate caring is what attracted them to nursing. While all humans have the ability to care, caring holds a unique meaning to nursing. Caring guides clinical practices.

The Value of Care


Most nurses, students, and nurse educators tend to devalue caring as a focus of study. Caring is generally invisible, hidden, and unrecognized by both the public and other health care professionals. To the patient, acts of caring are invaluable (PRICELESS, PRECIOUS).

The Invisibility of Caring


Nursing has been described as one of the most invisible arts, sciences, and certainly one of the most invisible parts of our health care system. (Gordon, 1997, p. xi) Nurses are involved in the most private aspects of patients lives. Nurses are compassionate strangers.
Intimacy is both invisible and vital to nursing care. Caring in general is culturally invisible and devalued partially because caring is associated with womans work. Many of the moral failures of the current health care system can be attributed to a lack of caring.

Moral Failure of Health Care


Contemporary health care
Depersonalizing procedures, detached standardized treatment Technological problem-solving Market-driven economics, cost containment, profitability Caregivers are rewarded for efficiency, technical skill, and measurable outcomes. Concern, attentiveness, and human engagement go unnoticed by profit-driven corporate health care.

Nurses are in an ideal position to rehumanize health care.

Caring Activities: Reward and Punishment


Nursing activities that are rewarded:
Efficiency Technical skill Measurable outcome

Nursing activities that are devalued:


Concern Attentiveness Human engagement

When We Dont Care, We Ignore


Individuals without health insurance Problems associated with:
Decreasing access to health care Care of the homeless and mentally ill Mistreatment of the mentally ill and elderly Rising infant mortality rate among the poor Rising prison populations Violence in the workplace or school Racism, sexism, and classism

Rising Visibility of Caring


Caring first became included in a definition of nursing in 1991. American Nurses Association in Nursings Social Policy Statement (1995) included caring as an important component in the nursepatient relationship. The Essentials of Baccalaureate Education for Profession Nursing Practice (1998) published by the AACN identified caring as a central concept to the practice of professional nursing. Increasing visibility of caring can also be attributed to annual National Caring Conference held since 1978. The Center for Human Caring, Watson, was established in 1986.

National Caring Conferences Goals to Increase the Visibility of Caring


Identify major philosophical, epistemological, and professional dimensions of caring. Explicate the nature, scope, functions, and structure of care and its relationship to nursing care. Clarify the major components, processes, and patterns of care. Stimulate nurses and others to systematically investigate care and caring.

A Call for Curriculum Revision


International Association for Human Caring American Holistic Nurses Association National League for Nursing

Behaviors Associated with Caring


Caring is difficult to describe or define because of our very familiarity with the concept.
Compassion Concern Empathy Interest Love Patience Protection

Other Behaviors Associated with Caring


Sharing Bearing witness Empowering Touch Tenderness Being with Commitment to Communication Comforting Listening to Reflecting Understanding Watchfulness Competence Trusting Valuing another Advocacy Assisting

Self Care for the Professional Nurse


Helping oneself grow and actualize Self-care builds self-esteem Creating a healthy lifestyle
Proper nutrition Activity and exercise Recreation Avoiding unhealthy patterns

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Self Care for the Professional Nurse


Using mind-body therapies
Guided imagery Meditation Storytelling Music therapy Yoga

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The Value of Reflective Practice in Nursing


Reflective Practice
Method of self-examination Involves thinking over what happened in a nursing situation Includes becoming aware of how one feels about oneself Recognizing how one thinks and acts Leads to new understandings and appreciations Requires discipline, action, openness, and trust

Reflective Journaling
Guidance from a mentor
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POST TEST

Question 1
Which of the following examples illustrates the principle of knowing the client? 1. 2. 3. 4. The nurse provides a back rub to help the client relax, and then makes the bed with clean linen. The nurse listens as the client describes how he has been caring for his diabetes at home. The nurse administers a piggyback antibiotic for a client with pneumonia. The nurse collects a urine specimen to send to the lab, and explains to the client the reason for the test.

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Rationales 1
1. This option aims to provide comfort. 2. Correct. This assessment activity gathers more information to help the nurse know the clients usual selfcare practices. 3. This option is a therapeutic, not an assessment, activity. 4. This option does not meet the aim of knowing the client.
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Question 2
Leiningers theory, culture care diversity and universality, would provide the best framework for assessing which of the following nursing situations?
1. 2. 3. 4. Because the Indonesian parents of an infant preferred to use hot/cold therapies to prevent seizures, they withheld treatment or care. Staff nurses on a hospital unit discuss how to reorganize client care to provide more continuity of staff with clients. Nurses in a community agency search for learning resources about intravenous therapy in the home setting. A nurse manager explores ways to assist new nursing graduates to develop clinical skills on the hospital unit.

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Rationales 2
1. Correct. In this situation, culture care diversity addresses the differences between Indonesian medical practices and traditional American practices. Universality addresses the similarities among the cultures. Since Leiningers theory addresses cultural elements relevant to nursing, option 2 is incorrect. Since Leiningers theory addresses cultural elements relevant to nursing, option 3 is incorrect. Since Leiningers theory addresses cultural elements relevant to nursing, option 4 is incorrect.

2. 3. 4.

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Question 3
The nurse sits with the client and holds the client's hand as his pain decreases. This situation is an example of the following caring practice: Nursing presence Assessment Knowing the client Empowering

1. 2. 3. 4.

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Rationales 3
1. Correct. The nurses presence is most significant in this situation. 2. Assessment is not the focus of the nurses action. 3. Knowing the client is not the focus of the nurses action. 4. Empowering the client is not the focus of the nurses action.
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Question 4
The nursing student reviews the pathophysiology of myocardial infarction, in preparation for the next days clinical experience. This activity is an example of which type of knowledge development? 1. 2. 3. 4. Empirical knowing Aesthetic knowing Personal knowing Ethical knowing

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Rationales 4
1. Correct. Empirical knowing is gained from studying scientific models and theories. 2. Aesthetic knowing arises from application in practice. 3. Personal knowing arises from selfexamination. 4. Ethical knowing arises from confronting conflicting values.
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Question 5
Which mindbody therapy is described by the following activity: The person sits quietly in a chair, breathing deeply and focusing on the mental image of a crystal?
1. 2. 3. 4. Storytelling Yoga Music therapy Meditation

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Rationales 5
1. Storytelling involves communication with others. 2. Yoga combines various postures with breathing practices. 3. Music therapy involves listening to music. 4. Correct. Meditation involves the described behaviors.
Copyright 2008 by Pearson Education, Inc.