The Conundrum of Caring in Nursing

Abstract

Caring as a universal human attribute has withstood the test of time. Caring was proven integral and weaved through the profession of nursing as the very foundation upon which the fundamentals and principles of nursing practice are grounded. The environment, political climate, complexities of patient care, escalating nursing workloads and advanced technologies has changed significantly since Florence Nightingale's day and has challenged the practice and genuineness of caring in many regards. It is possible to surmise that the lack of clarity and visible disagreement between nursing theorists has weakened the importance and necessity of caring in the nursing profession. However, the construct of caring remains critical to the nursing profession perhaps even more so now than in the past and it is up to us as respectful, compassionate and professional nurses to help ensure that caring in nursing surpasses these turbulent times and remains at the forefront of nursing practice.

Headnote

Abstract

Caring as a universal human attribute has withstood the test of time. Caring was proven integral and weaved through the profession of nursing as the very foundation upon which the fundamentals and principles of nursing practice are grounded. The environment, political climate, complexities of patient care, escalating nursing workloads and advanced technologies has changed significantly since Florence Nightingale's day and has challenged the practice and genuineness of caring in many regards. It is possible to surmise that the lack of clarity and visible disagreement between nursing theorists has weakened the importance and necessity of caring in the nursing profession. However, the construct of caring remains critical to the nursing profession perhaps even more so now than in the past and it is up to us as respectful, compassionate and professional nurses to help ensure that caring in nursing surpasses these turbulent times and remains at the forefront of nursing practice.

Key words: nurses, quality of work life, psychometric properties

The Conundrum of Caring in Nursing

Caring is the quality that constitutes our very nature of being human. It is a basic human attribute that people demonstrate toward each other (Boykin & Dunphy, 2002). Beare and Myers (1990) add that it is the altruistic act or feeling of concern for another human being. While caring is the most common, authentic criteria of humanness (Roach, 1992), that has dawned civilization, its theme has threaded the profession of nursing. As caring has become one of the greatest fundamentals in nursing, introduced by Florence Nightingale as being the essence of nursing (Chitty, 1993), some nursing proponents fear that it is no longer a central theme to the nursing profession and has become only second nature to the busy, overworked nurse in a technologically dominated setting. Nursing has struggled at length to clarify, accept and articulate the essence of caring in a way that would satisfy all nursing roles and embody all nursing knowledge and practice. In spite of it proven and recognized value in nursing, the construct of caring has met much opposition as well. Ironically, some suggest that caring is not essential to the nursing profession (Barker, 1995). It is the purpose of this paper to explore the phenomenon of caring and to highlight why it is still fundamental to nursing. To achieve this, the philosophy of caring, the role and benefits of caring as well as the challenges encountered will be explored for how they impact the presence of caring in nursing today, and current clinical expectations/experiences that would either support or oppose such an inquiry.

Philosophy of Caring in Nursing

First to be clear, caring in nursing occurs through two primary domains, one as a noun or the act of caring for another person when s/he are unable to care for themselves. Second, and the context of concern here, is the adjective of being a caring nurse such as occurs when a nurse displays actions of compassion, kindness and concern. By its very definition, caring is felt to be the central theme underlying nursing. Derived from the Latin word, nutricius (meaning nourishing), it is synonymous with caring (Chitty, 1993).

While caring is not unique to nursing, it subsumes all the attributes descriptive of nursing, a human, helping profession (Roach, 1992). Caring in such a manner reflects trust, intimacy and responsibility, elements deemed essential to professional relationships (Brilowski & Wendler, 2005).

The abstractness of caring transcends the material and phenomenal world, making it an increasingly complex issue for enquiry that stems from the historical developments of nursing and society at large. As a historical review of caring unfolds in this paper, it should become increasingly apparent how the abstract concept of caring is complex and how it is perceived by many to illustrate an ontology and epistemology of nursing, but yet, notoriously ambiguous (Brilowski & Wendler, 2005; Eriksson, 2002). Gadamer (1988) advocated that to understand caring one needs to delve deeper into reality and into the world of the patient, one that can be best achieved in a hermeneutical sense, to penetrate the core of nursing (Eriksson, 2002). Watson (2005) adds that it moves humans towards a deeper ethic of human belonging that affects all.

As nursing is a helping profession, the onus lays with individual nurses in the extent to which they perform their nursing responsibilities in a caring manner. This focus reflects what Newman, Sime, and Corcoran-Perry (1991) suggest, that caring in the discipline of nursing is one of a human health experience. This is achieved through the nurses' experiences as she turns inward to herself as a source of values and strength that further exemplifies the caring experience (Watson, 1979). The nurse who is cognizant of him/herself and others through selfreflection of personal experiences is one who is able to enhance his/her caring in a more holistic dimension (Davis, 2005).

The overall theme behind many a philosophy of nursing is caring. Lukose (2011) writes, "nursing is a caring science...human beings are connected to each other in the caring process; a nurse's humanity embraces the humanity of others to preserve the dignity of self and others" (p. 27). Caring involves being there for the patient or family in whatever way is needed at the time. This might involve being there to help medically stabilize the patient's illness and work through to recovery, and preparing the individual and family for discharge by tailoring care to fit the situation and supporting the family through this transition. Sadly, this may also involve being there to help the patient die with dignity and comfort, respecting the needs and beliefs of the family, and being there to provide them with emotional support. As nurses work through the care of their patients, their focus shifts based on the patient's needs; however, the aim is always to deliver nursing care with a caring attitude as care and caring are intertwined in nursing and impacts the one being cared for (Como, 2007).

As an epistemology, Watson (1990) calls for the inclusion of caring knowledge into nursings' meta-paradigm of person, environment, health, and nursing. She suggests that caring knowledge cannot be created in a void; it is to exhibit a soul enriching connectedness with nursing metaparadigm in order to be relevant to the discipline of nursing, as an aesthetic décor, so to speak. She further adds that "nursing is a caring science with ethical and philosophical implications.

Although Nightingale formally started what is now called the profession of nursing, whose artistic inclination was the essence of caring (Chitty, 1993), many biblical writings that pre-date Nightingale and nursing make reference to caring for the needy, sick and hungry in a general sense (Callahan, 2014).

While caring in nursing grew to be perceived primarily as an art, it has since taken on a science basis as well (Eriksson, 2002; Watson, 2005), but in any event remains fundamental to the practice of nursing (Roach, 1992; Schattsneider, 1992), as a combined entity of art and science (Watson, 1979).

The blending of the empirical research with an aesthetic learning opportunity is vitally important in the development of caring among humanistic professionals (Pardue, 2004). Caring allows for a delicate balance between the scientific knowledge base that nurses hold and their humanistic practice behaviors (Watson, 1979).

The Value of Caring

Through caring, a nurse employs an authentic genuine practice that is all encompassing and meaningful to the patient/family. Caring reflects a high regard for them as a human being (Roach, 1992); one worthy of utmost respect and dignity (Eriksson, 2002). The nurse portrays and stays genuine to him/herself as a concerned, committed and devoted health care professional who assumes an acceptable and unconditional stance to create an environment conducive to patient growth and healing (Lewis, 2003). His/her caring mirrors an inner connectedness, presence and genuineness inherent in such a giving profession as nursing (Watson, 1990). Such attributes have captured the very essence of how nurses effectively implement their practice to contribute significantly to a patient's perceived health and illness (Smith & Godfrey, 2002).

Another underlying assumption of caring is that it contributed immensely to the nurse's knowledge base. Such knowledge arose from an interpersonal relationship formed between the nurse and patient, a rich resource from which to learn, enhance one's already existing knowledge and engages the patient in a meaningful way (Watson, 1979), as the nurse sets out on a lifelong journey to deal with human life and needs to complement people's own accompanying historical and philosophical experiences (Eriksson, 2002). As the nurse uses his/her caring repertoire to employ both the scientific principles of nursing (Watson, 1979), as well as the qualitative esthetic patterns of knowing (Carper, 1978); s/he holistically addressees all aspects of caring pertinent to her patients' healing that exhibits a deeper and richer meaning and understanding (Nelms, 1996). Such knowledge is not only a requirement of the nurse (Newman, Sime, & Corcoran-Perry, 1991), but is utilized to lend guidance to the ethics, values and morals the nurse uses in how s/he thinks, feels and acts in her practice (McIntyre, 1995).

Viewpoints of Caring

Through the initial works of Florence Nightingale (Chitty, 1993), Madelaine Leininger (Leininger, 1984), Jean Watson (2005) and Martha Rogers (Fawcett, 1984), caring became historically rooted in and threaded through as the essence of nursing. While it became perceived as a necessity in how nurses assist patients on the continuum of illness to wellness, it became an interwoven theme and even synonymous with nursing itself. Watson and Leininger perhaps wrote at the greatest depth for how important caring is to the nursing profession, particularly, when considering one's cultural origins. Leininger for example, asserted that it's the one central, unifying domain that characterizes nursing for all persons (Leininger, 1984). However, at present, even Leininger grapples with the notion that caring seems to be fading in today's nursing and is minimized in importance, not only in the practice of nurses, but in nursing school curriculum where the emphasis on medical diagnostics and treatment regimens overshadow the importance of it (Leininger, 1984). She hence questions how faculty will instill in our nurses of tomorrow, the importance of caring in their profession. In today's recent literature, Leininger's notion of caring and its crucial importance in nursing is supported (Kenny, 1999; McEwen & Wills, 2002), in spite of opposition that suggests it is now submerged in a nurse's ritualistic and technological day that is of no value to one's healing (Farmer, 1992).

These opposing views to the importance of caring in nursing have in some cases been supported by nurse theorists who previously advocated for caring's rightful place in nursing. Such views have contributed immensely to today's caring elusiveness and perceived uncertainty in the profession and challenged the very reasons why caring is perceived as important. Musk (2004) and Clark (2004) however, surmise that such polarized views can and should be reconciled where all aspects of nursing are anchored in caring (Clark, 2004; Musk, 2004). While caring may not be unique to nursing it is certainly essential to it (Lewis, 2003).

Watson's work on her Theory of Interpersonal Caring is one theory that became embedded into nursing curriculum around the world. Caring, she suggests, is both an art and a science. "Nurses practice the art of caring when they reflect on their practice, not simply focusing on signs and symptoms but on the richer, deeper spiritual connections resulting from protecting, enhancing, and preserving a person's health" (Vandenhouten et al., 2012). Further, Watson adds that "caring science is the essence of nursing and the foundational disciplinary core of the profession" (Watson, 2008, p.17). In essence, it was Watson's Theory of Transpersonal Caring that helped identify caring as the core of nursing (Vandenhouten et al., 2012). Watson's Theory of Interpersonal Caring suggests that "nursing is a caring science with ethical and philosophical implications. With human beings connected to each other in the caring process; a nurse's humanity embraces the humanity of others to preserve the dignity of self and others. A holistic approach is used in the transpersonal caring relationship" (Lukose, 2011, p.27). Nursing researchers have used it again and again to prove and illustrate that the foundation of caring can be effectively incorporated into and beneficial for the nursing curriculums of many colleges and universities as well as hospitals and health care authorities (Burtson & Stichler, 2010; Porter, Cortese, Vezina, & Fitzpatrick, 2014; Spence Laschinger & Leiter, 2006).

The Threat

As the focus of nursing practice changes with the introduction of technological advances, increased workloads, and higher acuity patients, it is feared that the philosophy of caring in nursing will fade. The value placed on the medical model of caring as well, only reinforced the distance between the nurse and the patient because the emphasis was on the disease process itself, not the person or their needs (Clifford, 1989). The sanctioned definition of the American Nurses Association which included no notion on the importance of caring, only for nurses to diagnose and treat actual or potential health problems (Schlotfeldt, 1986), did not help maintain the focus of caring in nursing either. What perhaps initiated and contributed to this fear of a downward focus of caring and a shiftof emphasis in nursing was the opposing stance taken later by many nurse theorists. A loss to nursing now thought to be potentially recaptured only through post-modernism thought (Fry, 1992; Watson, 1999), as a restoration and re-connectedness with the human condition is attempted.

The Opposition

Nightingale's work and effort began the notion of caring as fundamental in nursing as she exhibited herself as a very caring being. Her voluntary visitations to the sick in the local hospital/community intrigued her to do more in caring for the sick, even at the dismay of her family and friends (Chitty, 1993). In an ontological sense, she portrayed herself as a very caring being, doing good for others and their poor health (Marriner- Tomey, 1994).

However, perhaps Nightingale lost sight of this caring notion, as it became only implicitly noted in her writings. Nightingale's emphasis on personal observation as being most important in nursing, as opposed to caring, became the impetus for such an assumption (Marriner- Tomey, 1994). Hilton (1997) similarly recalls how she posited nursing empirically, only as an addendum to medicine. Again, an effect of the medical model beliefs and influence. Her treatment to the Irish sisters, as well, during the Crimea war as they offered themselves to help the sick and wounded, dismissed any notions of caring she initially advocated for in nursing and cast the altruistic work of the Sisters of Mercy in the worst possible light (Doona, 1995). One of Nightingale's followers, Hildegard Peplau, later said that caring was not the essence of nursing and that as long as it is perceived to be, this female dominated trait will block men from entering nursing (Kenny, 1999). Barker et al. (1995) go as far as to suggest that caring reflects a selfishness of nurses that is conditional upon getting their own needs met first. Barker further adds that it is not the basis for the development of a profession.

Martha Rogers' humanistic theory on the Unitary Human Being was perceived to imply the importance of caring for others. With a focus on patients as whole beings and interacting entities, nursing was a humanistic science dedicated to compassionate concern, for maintaining or promoting good health of all people (Marriner-Tomey, 1994). Davis (2005) similarly advocated for a more caring presence of a nurse as being key in humanistic nursing. However, Rogers' implication of nursing as a caring, compassionate profession was, unfortunately, short lived, where she later expressed it was time to bury the whole idea of caring as the essence of nursing and nurses should begin to look at some substance in nursing instead, for it was "foolish" to think that caring is an identifying characteristic of nursing (Kenny, 1999). This fuelled support to the beliefs held by Thorne et al., (1998) who felt that caring is perhaps an unnecessary distraction in nursing. Is it any wonder then, that nursing students and nurses have encountered a caring crisis? (Ma, Li, Zhu, Bai & Song, 2013).

While some of nursing's leading theorists, Nightingale, Rogers and Peplau discovered the essence of caring in nursing but later opposed it, only Watson and Leininger held true to nursing's focus around caring. It remains unclear in history as to why their values and beliefs of caring being central to nursing were later self-contradicted, which leftthe philosophy of caring in nursing in turmoil and issues of non-caring behaviours such as those found in workplace bullying can breed (Adams, 2015).

Caring in Nursing Today

In light of caring's turbulent journey through time, it is of no surprise why its ambiguity in nursing persists. The self conflicting expressions of early nurse theorists created an uncertainty for their followers which further increased this ambiguity. Although caring today seems apparent in most clinical settings, it is perceived as something that has to be worked on. As nurses' workloads, increased use of machinery and fast paced work environment burden the boundaries of caring (Farmer, 1992; Barker et al., 1995; Thorne et al., 1998), Watson (1999) and Fry (1992) anticipate a resurgence of caring in nursing and its research. Watson (1999) suggests that as we move into an era of postmodern thinking, the simple act of caring in nursing will emerge in importance for how it benefits the sick and compromised. This contrasts previously identified views that nurses submerged caring themselves in a sea of tasks, rituals and mechanical tasks.

Today, in spite of the ambiguity of caring in nursing, much evidence abounds to illustrate how the concept of caring in nursing has positively impacted clinical nursing practice. Sumner (2005) suggests that while nurses require a higher level of skill and knowledge for technologically advanced machinery and tests, the hands-on approach is still needed, for nothing can replace this humanism aspect. The practice of advanced nursing, she suggests is wholly based upon the fundamental moral of caring. Technology can only do so much for the patient, physically and physiologically, not emotionally, spiritually or psychologically, as is needed (Roach, 1992). Hagedorn (2004) similarly suggests that while a fragmented healthcare system taxes the nurses' attention to one's emotional needs, the focus of the 21st century will be on the art of caring in nursing. As a profession, we have now witnessed this, as research into the effectiveness of caring surfaces (Burtson & Stichler, 2010; Porter et al., 2014). Hagedorn further adds that aesthetics, as a pattern of knowing will help promote the holistic view of the human and add strategically to prioritizing and promoting health care. Pragmatically, Thornton (2005) notes how the concept of caring is advantageously used today to increase patient and staffsatisfaction and to decrease the patient's length of stay in hospital.

Clinically, Hagedorn (2005) and Falk- Raphael (2005) have found that caring remains at the forefront of advanced nursing practice roles in a variety of settings. As Newman et al. (1991) have stated, if we just develop a unified focused statement about caring and nursing, then it would help constitute nursing as a professional discipline and help eliminate ambiguity about nursings' identity as a discipline, as is sometimes perceived. Furthermore, by having one unified focus, this could possibly open up avenues for nursing to advance in its practice even more and with increased accompanying credibility. The presence of caring in nursing's advanced practice roles is reassuring to the nursing profession, where new and emerging roles of nurse practitioners incorporate caring into their everyday practice with patients, whose competencies reflect the core caring dimensions of respect, compassion and dignity (Hagedorn & Quinn, 2004).

From a patient perspective, the caring presence that emanates from nurses, positively impacts patients' hospital experience (Davis, 2005). Such overwhelming evidence of the positive effects of caring in nursing minimizes Barker et al's. (1995) claim that caring is not important to nursing due to its changing needs, social structure, and the profession itself. To nurses of today, it has become increasingly obvious how caring contributes to nursing's ontology and epistemology, unlike the confusion created by Thorne et al. (1998), Farmer (1992), Barker et al. (1995), and the nurse theorists themselves (Marriner- Tomey, 1994; Kenny, 1999).

While the ambiguity and elusiveness of caring in nursing has brought increased attention to its presence so much so as to break it offinto a science of its own (Smith & Godfrey, 2002), nowhere is it assumed that it would be lost from nursing either artistically or scientifically; but simply just a renewal of the notion itself from a research, practical and societal perspective, posing no threat to nursing as a discipline. The acceptance and utilization of caring in nursing as both an art and science to reflect the underlying importance of caring in nursing is advocated by many (Hagedorn, 2004; Pardue, 2004).

Both positions have in fact become very much formalized through nursing theories and research and enhanced by scholarship in other related fields (Watson & Smith, 2002). While the importance of the field of caring continues to grow into an art and science of its own, or as a philosophical-ethicalepistemic field of study (Watson & Smith, 2002), where if scientific medicine and technology says nothing more can be done for the patient, the nurse can still care to give strength to the patient's perceived inadequacies and vulnerabilities (Watson, 1979; Gaut, 1992), the growth of nursing would be void without it. Caring from both an art and science perspective would complement one another, ensuring that all issues and ambiguities in nursing could potentially be accounted for and explained (Pardue, 2004; Hagedorn, 2004; Watson & Smith, 2002), while holistically addressing a patient's need (Eriksson, 2002). Hence, permitting the discipline of nursing to proceed in a manner that is in keeping with their identified codes of ethics and standards of practice (Canadian Nurses Association, 2004).

In spite of the fact that Bishop and Scudder (1991) imply that caring would not be missed because of society's prevailing belief system based on Cartesian dualism, where the body is viewed separately from the mind, such a large global assumption for all people of all cultures reflects only a minimal snapshot, with unpromising potential to surpass the overwhelming evidence suggesting otherwise (Bishop & Scudder, 1991).

Finally, for the nurse theorists who contradicted caring as no longer essential to nursing (Kenny, 1999), no known research to support those assumptions seems to exist, making them only isolated statements with minimal foundation for validity.

Conclusion

Caring has remained the art and science of nursing's essence through time and into today's practice, in spite of some perceived fears of its loss. It seems somewhat ironic that the very proponents of caring in nursing later came to dispute its necessity and presence. This belief gained momentum on the premise that nurses were now too focused on technology, workloads and acuity issues and the lost sight of the value and ethic of caring, which clinical research illustrated it was not so. On its turbulent journey through time the ontology and epistemology of caring remains. The anticipated resurgence of caring in nursing through postmodern thought brings even more optimism for caring to continue to be the central focus of nursing now and in the future in spite of perceived barriers to its relevance.

References

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