As the nursing profession continues to confront and manage health care problems in a changing world, many gray areas exist. Although uncertainty will always exist, it is wise to seek clarity of process and purpose, particularly for nurses who are new to the profession. Caring is a concept central to the nursing profession. Although references to caring in the literature are abundant, there is little clarity about the definition and process of caring. Because of this ambiguity, the teaching, learning, and evaluation of caring is, at best, a tenuous process. Given that nursing theory embraces the concept of caring as central to practice, a well-defined and articulated framework of the concept is essential. This article offers a clarified definition for caring and a framework for teaching and evaluating caring in practice.
Traditional Views of Caring
Most health care professionals would agree that caring is at the heart of their profession. Most people seeking treatment in health care settings wish to be cared for in some way. Extensive discussions of care and caring are found in the nursing and other professional literature. However, there is little agreement regarding the meaning of the word. Caring is the central aspect of nursing (Appleton, 1990; Koldjeski, 1990; McCance, McKenna, & Boore, 1997; Watson, 1979). It is more than just performing nursing procedures. It is an attitude of nurturing and helping another person to grow (Lindberg, Hunter, & Kruszewski, 1994).
Watson (1979) defined nursing as the science of caring, in which caring is described as transpersonal attempts to protect, enhance, and preserve Ufe by helping find meaning in illness and suffering, and subsequently gaining control, self-knowledge, and healing. Caring is identified by carative behaviors, such as developing trust, providing support, and assisting with human needs gratification. Leininger (1981) described caring as essential to human growth and development and specified that it is defined by individuals' culture. She listed caring behaviors such as giving comfort, empathy, compassion, and sharing (Leininger, 1981). However, neither theorist described exactly what caring is or how it can be accomplished.
Oddly, concept analyses do not lend clarity to a definition of caring. According to McCance et al. (1997), there are four critical attributes of caring:
* Serious attention.
* Providing for.
* Getting to know the patients.
Antecedents of caring include amount of time, respect for individuals, and an intention to care. The authors confessed the consequences of caring were difficult to ascertain and defined them through a case exemplar (McCance et al., 1997). Morse, Solberg, Neander, Bottoroff, and Johnson (1990) found that caring is composed of five perspectives:
* A human trait.
* A moral imperative.
* An affect.
* An interpersonal relationship.
* A therapeutic intervention.
Again, the definition of caring and how it can be achieved was not addressed.
Nursing education and education in general report similar ideas about caring. The commitment to care about students is central to concepts of good teaching. Caring is described as an interpersonal experience of human nurturing, warmth, connectedness, and love (Weinstein, 1997). It involves developing rapport and going out of one's way to provide learning experiences geared toward students' attributes. Appleton (1990) reported three aspects of caring in nursing education - it is expressive, a process, and has an environmental aspect. However, these diverse descriptions do little to define the concept or explain how to go about caring.
Poetic, inspiring, and thought-provoking statements frequently are used to express the nature of caring. According to Husted and Husted (1997):
Caring is the essential fuel of a nurse's interaction with her [eie] patient. It is an essential means of understanding the needs and purposes of her [sic] patient. Without this, nothing can produce a successful chain of cause and effect interaction between them. (p. 17)
Greene (1990) stated:
I cannot but hope that more and more practitioners will respond to the caring imperative and think what it means to choose themselves in accord with its demands... caring is a spectrum of human experiences, emotions and ways of being in the world, (p. 29)
In addition, Appleton (1990) advised, "Caring as an ideal way of being in the world, and one that persons consciously strive to become, is realized by studying caring as the essence of nursing" (p. 81). These ideas certainly strike a familiar note with most nurses but still provide few clues about the nature of caring.
Although there obviously is an affective component to caring, there is a psychomotor component as well. Traditional definitions of caring indicate nurses should feel something and do something. However, these feelings and actions have not been clearly delineated. By what method do nurses provide support or comfort, develop rapport, educate, and manage physical symptoms? How can educators hope to teach new nurses about caring if they cannot explain it?
When Caring Is Done Poorly
One thing is certain, although no one has explained exactly what caring is, there is agreement that if nurses do not care appropriately, they will make things worse for their patients and themselves. Caring done poorly appears as playacting, pretending they have the feelings they think they should have (Husted & Husted, 2001). Nurses also can care badly under the control of the rules of codependency, behaving with self-sacrifice while becoming resentful of their patients and negligent of themselves. Poor caring creates caregiver stress and burnout (Almberg, Grafstrom, & Winblad, 1997; Ashforth, & Lee, 1997; Farber, 2000; Greenglass, Burke, & Fiksenbaum, 2001; Whitaker, 1996).
Educators also fail in their task when they care poorly. Inappropriate behavior, disrespect, and ineffective learning environments result when caring goes awry in the classroom (Weinstein, 1997).
A New Definition of Caring
Traditional definitions of caring focus on an affective state that should be developed and somehow conveyed to patients through verbal communication and psychomotor skills. Nurses' behaviors will evidence their willingness and ability to care. This idea makes sense to nurses but remains vague. A clarifying definition is needed to serve as a framework for teaching and evaluating caring in nursing practice. For this reason, caring should be defined as offering of self. This means offering the intellectual, psychological, spiritual, and physical aspects one possesses as a human being to attain a goal. In nursing, this goal is to facilitate and enhance patients' ability to do and decide for themselves (i.e., to promote their self-agency) (Husted & Husted, 2001). Nurses must prepare themselves in each of the four aspects to be competent to care.
The Intellectual Aspect
The intellectual aspect of nurses consists of an acquired, specialized body of knowledge, analytical thought, and clinical judgment, which are used to meet human health needs. Nurses prepared with knowledge and clinical expertise will have much to offer in the way of care. Because health problems exist in a holistic perspective, it is essential for nurses to have a liberal education. In addition, nurses continually must seek updated information and experience as the nursing knowledge base grows.
The Psychological Aspect
The psychological aspect of nurses includes the feelings, emotions, and memories that are part of the human experience. Nurses offer their understanding of the human condition to meet psychological needs. Nurses need to be aware of how their own human experiences have shaped who they are and who they will become. They then can understand and accept how the same is true for others with different experiences. This awareness allows for empathy and facilitates communication between diverse individuals.
The Spiritual Aspect
The spiritual aspect of nurses, as for all human beings, seeks to answer the questions, TVhy? What is the meaning of this?" These questions are especially important for nurses because they frequently encounter people who are asking themselves those very questions. Nurses must understand their own struggle with the search for meaning and accept that although there are many answers, the questions are the same. It is the questioning and searching, which are common to all, that nurses facilitate and support.
The Physical Aspect
The physical aspect of nurses is the most obvious. Nurses take thenphysical bodies to the home, the bedside, and the field where they offer strength, abilities, and skills to attain a goal. For this task, nurses first must care for their own bodies, and then they must be accomplished and 8kulfiil in nursing interventions. This requires dedication to fitness and continued skills updating.
Consider the following scenario that demonstrates caring. A nurse enters a patient's room. A foul odor nils the air. The patient has soiled the bed. The patient yells angrily, "Well, it's about time you got here." The nurse realizes the patient is embarrassed by the situation and says, "Oh, I see you need some help. Let's get things back in order here." As the nurse begins, the patient says, "I wonder if things will ever be back in order for me. This is so humiliating." The nurse efficiently accomplishes the task, avoiding unnecessary inconvenience or discomfort to the patient, and replies, "Well, I'm sure this is not the way you usually go about your business, but for me, it's business as usual. So well just breeze through this and get back to the business of getting you back to business." The patient laughs a bit, then begins to cry, "Why is this happening to me?" The nurse sits down and says, "What is it that's happening to you?"
In this scenario, the nurse brought to the situation all she possessed - intellectually, psychologically, spiritually, and physically - and offered it to the patient to accomplish the goal of nursing. The nurse cared.
Developing Caring Practice
Certainly holistic use of these four aspects of human beings is evident when managing health problems. However, it is necessary to examine each aspect separately to ensure nurses are attending to each, not depending on only one. It is important for nurses to cultivate a strong knowledge base and reasoning skills and to develop psychomotor skills to efficiently meet patients' needs. It is equally important for nurses to develop awareness of themselves regarding their own psychological and spiritual foundations so they may respond appropriately to others. Caring demands a great deal of self-awareness and self-development. Husted and Husted (2001) asserted that this need for nurses to be well versed in their own human nature "offers a benefit to nurses that is greater than any benefit offered by any other occupation on earth" (p. 160). To be effective professionals, nurses must understand and participate in thenown humanity. Socrates believed the unexamined life is not worth living. With regard to caring, the unexamined nurse is not worthy of nursing.
Using these four human aspects as a framework, nurse educators can more easily convey all the manners in which nurses respond to patients in caring ways. There is emphasis on the need to develop a strong background in nursing knowledge and skills, but the framework also supports the need for nurses' personal self-awareness and self-development. Students may assess their own caring by examining their responses to patients in terms of the four aspects.
Because the nursing profession claims caring as a central concept, nurses must be prepared to define and describe it in terms that may be clearly understood and taught. Presenting caring as an indescribable set of feelings and actions serves neither professionals nor patients. Caring defined as offering of self clarifies the actions that must be taken and provides a framework for teaching and evaluating the process. In addition, caring as offering of self alerts nurses to the need for holistic preparation and continued development for nursing practice.
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